When a Higher Cost Health Insurance Plan Makes Sense

The costs of medical care are sky-rocketing in the United States, and this includes in vitro fertilization (IVF).  If you live and work in a state that does not mandate IVF health insurance coverage, then you might want to consider relocating if your health insurance plan excludes IVF coverage.  It might actually save you financially in the long-term!  According to a 2011 article published in Fertility and Sterility by Patricia Katz et al, a total expenditure of $61,377 was the median cost per successful IVF patient outcome among their study subjects.¹  Since the Affordable Care Act does not mandate IVF coverage, it may be difficult to obtain insurance providing IVF coverage outside of the 15 states that do.  If your employer does offer health insurance covering IVF, it may be preferable to choose one with a higher monthly premium if it covers more of the possible costs incurred in the course of your medical visits.

In preparation for IVF, hormonal therapy (i.e., GnRH agonist, follicle-stimulating, and/or luteinizing) will likely be initiated by the physician that may involve daily injections for a couple of weeks.  In August 2012, an article published online in Reproductive Biology and Endocrinology by Sills et al reported higher non-reimbursed medication costs for GnRH antagonists than GnRH agonists.²  Their finding illustrates the importance of clarifying the medication coverage of your specific health plan.

A huge surprise to patients of outpatient clinics at medical centers is that the organizational units generally bill separately.  Therefore, you can receive a separate bill for the office visit, lab tests, pharmacy, and other treatments.  Insurance companies view these as separate claims—and each must be coded correctly for reimbursement.  Many health insurance companies cover medications provided at a medical center and by prescription for use at home at vastly different rates.  If you are unsure of whether your insurance will cover your entire hormonal treatment regimen, contact your health plan’s Member Service representative to understand the coverage terms before you receive a walloping bill!

Even if you are lucky enough to have an employer-paid plan—or an individual policy—that covers the costs of IVF, you need to discuss the terms of coverage with a Member Services representative to ensure that you understand what procedures, lab tests, and pharmaceuticals your insurer will cover.  Clinical staff are hired at health insurance companies to review claims and seek loop-holes to cut costs.  If any therapy undertaken does not meet their exact parameters, they may deny the claim.  If you feel it should have been a covered expense, submit your grievance in writing within the time period allowed by the insurer.  This can result in a reversed decision in your favor—saving you money.

Assuming you don’t plan to pay out-of-pocket, one of the most important decisions you make related to undergoing fertility treatment may be your health insurance.  For that reason, it is wise to plan ahead for the financial costs.  Do you really want IVF or would adoption be a viable alternative for you?  And, the fertilization costs are just the beginning—having a baby is expensive!  Seeking the advice of a financial planner may enable you to budget better for the non-covered costs involved in your fertility treatment regimen—not to mention pregnancy-related costs!  The stress involved in parenting is enough without adding a medical debt burden to the stew.   Outcome uncertainty inherent in undertaking IVF makes it vital that costs—offset by a sound choice of health insurance coverage—be considered along with the emotional need to have children.  After all, you could have twins!

Hope this was helpful! If you have any comments or questions please don’t hesitate to write them below.

Cheers!

References:

1)      Katz P, Showstack J, Smith J, et al.  (2011).  Costs of infertility treatment: Results from an 18-month prospective cohort study.  Fertility and Sterility 95(3): 915-921.

2)      Sills ES, Collins GS, Salem SA, et al.  (2012).  Balancing selected medication costs with total number of daily injections: a preference analysis of GnRH-agonist and antagonist protocols by IVF patients.  Reproductive Biology and Endocrinology 10:67.