By Susan Hammerberg, Fertility Financial Expert
If you are looking to make use of your company’s healthcare benefits, it can be overwhelming to decide which insurance plan is the right fit for you when it comes to family planning. In this article, we will break down some key factors to consider in order to help you evaluate your options and maximize your deductible on your fertility journey.
When it comes to signing up for insurance, it’s important to consider how you can optimize your deductibles. Deductibles are the amount of money you must pay out-of-pocket before your insurance coverage kicks in. By understanding how to choose the right deductible options, you can ensure that you are getting the most out of your insurance policy while also saving money.
One way to optimize your deductibles is by carefully assessing your financial situation. If you have enough savings to cover a higher deductible in case of an emergency or accident, opting for a higher deductible can lower your monthly premiums. On the other hand, if you prefer a lower upfront cost and are willing to pay slightly higher premiums each month, choosing a lower deductible may be more suitable for you and your family.
Additionally, when it comes to family-building, it’s important to understand what expenses are covered by your insurance policy before making any decisions about deductibles. Some policies may have specific limitations or exclusions that could impact how much you would need to pay out-of-pocket.
Enrolling in an insurance plan
Open enrollment refers to the period when individuals can sign up for a new insurance plan or make changes to their existing insurance options provided by their employer. Open enrollment typically occurs during November and December but can vary based on your plan or employer. During this period, employees are given the necessary materials for them to review, ask questions regarding plan options, and proceed with plan enrollment. They will have the choice to add or remove dependents, opt for a different medical plan, or keep their current plan, if available.
Some insurance companies may offer complete coverage for all fertility treatments, while others may only cover specific procedures, and some may not offer any infertility coverage at all. It’s important to note that even if your plan does cover infertility care, there may be limitations or restrictions on the covered expenses. For example, some plans require that you complete a certain number of intrauterine insemination (IUI) cycles before starting fertility treatments that include assisted reproductive technology like in vitro fertilization (IVF).
The most frequently offered health insurance plans by employers are EPO, HMO, PPO, POS, and HDHP:
- Exclusive Provider Organization (EPO) plans only cover providers and hospitals within their approved networks. EPOs work in partnership with doctors and hospitals to ensure the highest quality care for their plan members. These approved caregivers and facilities are known as “network providers” or “in-network providers.” It is important to note that EPO members are required to utilize in-network resources whenever possible for their healthcare needs. However, emergency services are usually covered by these plans regardless of the provider or location. If you have fertility issues and are planning for treatment, verify your physician is in network.
- Health Maintenance Organization (HMO) plans operate based on a network system. This network consists of contracted providers who are responsible for your insurance coverage. Typically, HMO plans only cover medical services from these specific doctors, laboratories, and hospitals. However, emergency medical care may be an exception to this rule. It is usually mandatory to choose a primary physician who will oversee most of your treatments. If you need to consult with a fertility specialist for testing (like blood work, ultrasounds, or a semen analysis) or treatment (like IUI or IVF cycles), a referral will be required.
- Preferred Provider Organization (PPO) plans encourage members to use the insurance company’s network of preferred doctors, and you usually won’t need to choose a primary care physician. No matter which healthcare provider you choose, in-network healthcare services will be covered at a higher benefit level than out-of-network services. It’s always important to check if your provider or fertility specialist accepts your health plan so you receive the highest level of benefit coverage. However, you will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a copayment for certain services or be required to cover a certain percentage of the total charges for your medical bills.
- Point of Service (POS) plans combine elements of both HMO and PPO plans. Like an HMO plan, you may have to designate a primary care physician (PCP) who will then make referrals to network specialists when needed. Depending on the plan you have, services provided by your PCP are typically not subject to a deductible, and preventive care benefits are usually included. Like a PPO plan, you may receive care from non-network providers but with higher out-of-pocket expenses. You may also be responsible for copayments, coinsurance, and an annual deductible.
- A High Deductible Health Plan (HDHP), which may or may not be linked to a Health Savings Account (HSA), is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more healthcare costs (your deductible) yourself before the insurance company starts to pay its share. An HSA may be linked to your care; the money you put in an HSA is not taxed and can be used tax-free on eligible medical expenses. To have an HSA, you must be enrolled in an HDHP.
Using your insurance
Now that you have some information on the different types of insurance, you can start thinking about how you expect to use your plan. This is an important part of the enrollment process, as the best plan for one person may be the worst option for another based on individual or family needs.
Here are a few health insurance terms that you’ll want to know:
In-network healthcare providers:
Healthcare providers that are part of the network and accept your plan.
Healthcare providers that have no contract with your health plan and can charge you a higher, full-price rate for their services.
Premium is the amount you pay for your health insurance every month. Your employer may cover a portion or all of your premium each month.
Prior authorization is approval from the health plan that may be required before you fill a prescription or go through fertility treatment to be covered by your plan.
Referral is a written order from your PCP or doctor of obstetrics and gynecology (OBGYN) for you to see a fertility specialist or reproductive endocrinologist (RE), or to receive certain medical services. If you don’t get a referral first, the plan may not pay for the services.
Deductible is an amount you pay for covered healthcare services before your insurance carrier pays.
Copayment is a fixed amount you pay for a covered service (such as an infertility treatment).
Coinsurance is the percentage of the costs of a covered service you pay after your deductible.
Excluded services are healthcare services that are not covered. Some plans exclude fertility services, such as IVF.
The maximum limit is a cap on the benefits you may get from your insurance company.
Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren’t covered.
Selecting your insurance plan
It’s worth checking your benefits if your health has changed recently, or if you plan on seeing a specialist, like a fertility specialist. You should also make sure to check for prenatal benefits and exclusions. Some things that you want to think about for yourself, spouse, and dependents include:
- How often do you or will you see your primary care physician?
- How often do you or will you see a specialist (fertility specialist or reproductive endocrinologist)?
- Do you have any upcoming surgeries planned (for fertility, like a hysteroscopy)?
- Are you planning to start or continue reproductive medicine, fertility testing, and/or treatment?
- What prescriptions (for fertility) are you or will you be taking on a regular basis?
- Will you require lab work and/or ultrasounds on a regular basis (for fertility)?
If you are generally healthy and only find yourself going to the doctor once a year for checkups, a low-premium, high-deductible plan may be the best option for you. On the other hand, if you fill several prescriptions each month, see your doctor frequently, and are planning to see a specialist for fertility testing and treatment, you may want to opt for a plan that you pay more for each month, but saves you more on the healthcare services you will be using the most.
Be sure to review your individual health insurance plan and benefits carefully to understand what fertility clinics, treatments, and care are covered and what costs you may be responsible for. Remember that this may include costs for deductibles, copayments, coinsurance, diagnostic testing, and medications, as well as procedures such as IVF treatment, which could include multiple egg retrievals and/or embryo transfers. Also, know that the cost of IVF often excludes the cost of medications, and those may be covered in different ways under certain plans. If you are unsure about your coverage, it is best to contact your employer’s human resources (HR) department directly. They can provide you with specific information about the plans being offered and answer any questions you may have.
After you evaluate what exactly you need from a plan, you can look at the options that your employer has provided you. Each plan should have a summary of benefits that outlines what it covers. Go through the benefit summaries for each of your options, taking note of which ones match your healthcare needs. If you wish to continue seeing your current doctors and healthcare providers, you’ll want to look at whether they are in a plan’s network. You can see if a doctor is in-network by visiting the insurance carrier’s website or calling your doctor’s office directly.
Next, compare the out-of-pocket costs of each plan. Compare your monthly premium to your expected savings based on the coverage and your average healthcare needs. While you’ll certainly want to make your selection before the enrollment period ends, take your time to choose the plan that will be most beneficial to you. If you have questions, don’t hesitate to ask a member of your employer’s HR or “people” team.
Know that if an employee experiences a qualifying life event, they can typically change their health insurance outside of open enrollment. However, employees must make their selections during the open enrollment period to ensure they have the appropriate coverage during the year. Be sure to communicate with your HR team immediately if you fail to enroll during open enrollment.
In conclusion, optimizing deductibles when signing up for insurance involves carefully assessing your financial situation and risk tolerance, considering any changes in coverage or rates at the beginning of the new year, and understanding what expenses are covered by your policy. By taking these factors into account, you can make informed decisions that best suit your needs for your own fertility journey and help save money on insurance costs as you go through the family building process.