Jan 20, 2016

Affordable Healthcare: Can Obamacare help save you money during Infertility Treatments?

Good morning loves.
I am writing today on a topic that is near and dear to my heart: infertility and trying to maximize your dollar.
It's a shame that we have to pay through the nose to get the treatment we deserve, and I'm here to shed a little light on some of the changes in healthcare these days.
Maybe it can help you save a few (or many) dollars, in the long run.

Now, I don't claim to know all the answers. I am not an insurance broker nor do I work in the healthcare industry. I am in HR and have a general understanding of how insurance works. I am not here to make money off of your medical changes, I am simply writing about what I know our options are these days, in the hopes that I can help someone look into alternatives, should they feel overwhelmed with the mortgage payments we call infertility bills.

Take what I say with an open mind, and always always ALWAYS be sure to be an advocate for your own health and insurance. You have to make the calls and do the reading to make sure the switch, if any, works best for you and your family. But it could be worth it.

If you are not into crunching numbers with me, nor are infertile...this post may not be for you.

A little back story...
I love insurance. I really do. It's sick, I know. But I love making something that we have to pay for anyways, work in my favor.  We are in a developing time where Obamacare has entered the medical insurance market and changed the way we look at our coverage.
We are no longer bound to the big box company insurance. We are no longer bound to settle.
Sure, your company's monthly premium may be drastically lower than going out on your own, but in the long run, does it have the coverage you need for all of those out of pocket expenses that may come up as you journey through infertility and IVF treatments?

What if you need genetic assistance? What if you need multiple treatments? What if you need new testing, more meds, more hope? Shouldn't your medical coverage actually help you through dire times?

Now, I will admit....there are a lot of states that don't provide any sort of state mandated infertility coverage.

It's appalling that we are not further along at this point, and to those of you, I am sure there are a bunch of resources for discounted Rx medication, injections, etc. I am sorry but I do not have information on those discounted programs, but there are plenty of ladies in the TTC world that do.
Especially on Instagram....reach out and ask questions.

THIS is a list of the states WITH mandated coverage. There are 15 states with some aspect of infertility coverage. Each state has their own rules and limitations, of course, so be sure to read up on your state specifically when making this decision.

For Illinois, where I reside, the mandate on the website has a gray area that says group insurance and HMO's only....however, I can attest that I recently purchased individual PPO insurance for 2016 and do have the same coverage as a larger group insurance.

There are key elements when choosing a new insurance plan.

Enrollment Date: Most states still have open enrollment by January 31st for coverage starting March 1, 2016. Don't delay if you are looking to save money for 2016!

Check your Current Insurance: Find your Schedule of Benefits or request a copy from your company's broker or access it on your online account. This will give you an overview of coverage. Included in this document should read something to the tune of "Infertility treatments" as Included Coverage.
You can request a complete benefit booklet (typically 100+ pages) to fully understand what is covered.
Or call the insurance directly, they typically can give you more in depth information that the summary.

If infertility treatments is listed in the excluded section....there is no changing that.

Example: my current employer has a self-funded medical plan, therefore, we are exempt from including the Illinois mandate for infertility coverage....shitty, huh? 
Most self-funded insurances have the same exemption.

Premiums: More than likely, switching to your own insurance will up your monthly premium costs. These costs do not go towards your deductible in any way, it is simply the amount you pay to have the coverage in the first place.

Example: my employer's insurance was $305 for my spouse and me to have PPO coverage. 
I now have my own insurance plan and it costs me $299 just for myself.

Deductible: This is the minimum amount you will owe in a calendar year of insurance coverage before your insurance starts kicking in at 100%. The lower the deductible, the higher your premium, typically.
There are additional items to consider besides the deductible though.
Co-pays and monthly premiums do not count towards your deductible.

Co-Insurance: Your best bet is to look for a 0% co-insurance. Co-insurance is paid on top of your deductible, not with it. The way it works is if your co-pay is 20%, for example, and the service was $1,000....you owe $200 more even after your deductible payment.
The lower co-insurance percentage, the lower your max out of pocket expenses will be.
Even if you max out your deductible, the co-insurance still applies until you reach your out of pocket max.

Max Out of Pocket: This amount may or may not be higher than your deductible amount. Ideally you want your max out of pocket and deductible numbers to match. That would mean you likely have 0% co-insurance. This is one of the most key numbers when trying to budget for IVF. If your deductible is $2,000, but your max out of pocket is $10,000.....just assume you will end up paying $10,000 for the year.

Example: I chose an insurance plan that has a $3,500 deductible and max out of pocket of $3,500. I have 0% co-insurance. My plan is a PPO HSA, which means every single thing I pay for up to $3,500 is paid at full price. 
There are no co-pays. 
If I meet with my RE and it costs me $250 out of pocket, then that is what I pay. 
The benefit to this is, everything I pay for goes towards meeting my max out of pocket/deductible....get it?

Lifetime Maximum: This information can get tricky. It can be in the form of amount of services provided, or monetary maximums, or both.  From what I have uncovered, all infertility treatments have some sort of limit to them, regardless of how good the insurance is.

Example: My insurance allows for four (4) full oocyte retrievals per the lifetime of my insurance (one year). I am allowed as many transfers as necessary without penalty. 
PGD is covered if deemed medically necessary. PGS is not. It is considered experimental.  
This information is outlined in the benefits booklet, however, I did have to call my insurance provider to confirm if egg retrieval "banking" is allowed, prior to an actual transfer. It is. Up to four. Everything above and beyond that is out of pocket.

Finally...Cancelling your current insurance: Once you have decided on a plan, completed the online enrollment, and paid for your first month of March, you're golden. At the end of January or beginning of February, you will need to send an email to your broker/HR Manager/person who handles medical insurance enrollments, terminations, or changes, that states you are cancelling effective February 29th, 2016.
You have to give the request 30 days in advance of cancellation.
Also, coverage cannot end in the middle of a month. You will have coverage through the end of February.

PHEW!!! That's a lot to consider, right?
BUT IT'S WORTH IT. A little planning can go a long way.

IVF is super expensive. Most people cannot afford one complete cycle, much less two or more, without depleting their savings and/or taking out a loan to cover the costs on their own.

If you can? More power to you. You are the 1%.

The average costs for one standard (fresh) round of IVF is approximately $25,000 out of pocket.
But what if you need genetic testing?
Don't forget all those injections!
What if you need more than one round of IVF?
What if you need to freeze your embryos and transfer at a later date?
What if you are using a donor embryo?

The costs can really add up.
Getting a genetic DNA test completed for you and your spouse is around $200.
Testing a set of embryos using PGD or PGS, including the biopsy of the cells and transfer to the genetics lab is approximately $5,500. For one round.
Freezing, although typically not covered with any insurance, is around $1,200 for the year
Medications, per cycle, range in price from $3,000-$7,500.

So, the reality is...if you can bear to wait a couple months to get things going (which, lesbihonest, is a drop in the bucket compared to all these prior years of failed tests, right?) it's absolutely worth it to look into different medical options.
The overall pricing difference is monumental.
It could cost you between $4-$10k for an entire year's worth of infertility treatments instead of $100K or more (assuming you do four complete IVF cycles and all the fun stuff that goes with them).

That alone would make me wait. In fact, it did make me wait.

And because I want nothing more than for us to have a bunch of healthy bouncing babies in our near future, I am more than thrilled to help people with their decisions. 
Again, I don't know everything about all insurance options, and there are typically a lot to choose from, but I can absolutely help point people in the right direction should you require it.

Please e-mail me at handsonpantsoff@gmail.com or DM me on IG (@tgendooza) with any questions and let's get knocked up!!
Thank you so much for reading!!


  1. I could have used your help last year when I had to get private insurance! I was definitely overwhelmed... And was also paying over $300 a month for just me. This is very helpful to a lot of people!

  2. This was helpful, just in general . . . insurance is so confusing so thanks for helping break it down! I'm simply amazed at how expensive all the medical field has gotten.