November 18th, 2024 | 10 min. read
Finding out that the care you need isn't covered by insurance is beyond frustrating, especially if you plan to undergo fertility treatments in the coming year. This guide breaks down the basics of open enrollment, how to evaluate your current insurance plan, and how being proactive now can increase your chances of success.
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Will my fertility treatment be covered in 2025?
The answer to this all-important question is (as you might expect) fairly complicated, and varies widely based on your individual insurance policy, where you live, and other factors.
Let's not sugarcoat it - the thought of not being able to achieve your biggest hopes and dreams due to a lack of insurance coverage is beyond frustrating. And with the cost of IVF ranging anywhere from $15,000 to $30,000+ per cycle out-of-pocket, paying for treatment with existing funds isn't a feasible option for most people.
So, how can you pay for fertility treatment? Before you resign yourself to taking out a large personal loan or putting your family-building dreams on hold for yet another year, let's review what you can do right now to optimize your coverage.
Note: Illume Fertility assigns each patient a financial counselor to help them evaluate their insurance plan and get the most out of any existing insurance coverage.
Open Enrollment 101
The open enrollment period is an annual window of time when you can enroll in, switch, or make changes to your health insurance plan. Understanding the key aspects of this period is essential to making informed decisions about healthcare coverage.
Here are the most important things to know:
When is open enrollment?
The open enrollment period typically occurs once a year.
For most health insurance marketplaces in the U.S., the period runs from November 1 to January 15 (though exact dates may vary by state or employer). Always check to see to see if your state has an extension.
Coverage typically begins on January 1 if you enroll by the deadline (which is December 15 for most marketplaces). If you enroll later (e.g. between December 16 and January 15), coverage may kick in on February 1.
Note: Outside of open enrollment, you can only make changes if you qualify for a special enrollment period (SEP), triggered by life events such as:
- Marriage or divorce
- Birth or adoption of a child
- Loss of other health coverage
- Moving to a new area with different plan options
What can I do during open enrollment?
- Enroll in a new health insurance plan: If you don’t currently have coverage, this is the time to sign up.
- Change your current plan: You can switch plans or adjust your coverage to better suit your budget or expected needs (such as fertility testing or treatment).
- Renew your existing plan: Review your current coverage and confirm if you want to keep it for the upcoming year.
Types of Plans
Insurance plans available during open enrollment typically fall into these categories:
- Employer-sponsored plans: Offered through your job.
- Marketplace plans: Government-regulated plans available on healthcare exchanges (e.g. Healthcare.gov or state-specific exchanges).
- Medicare enrollment: If you’re eligible for Medicare, open enrollment occurs annually for selecting or switching Medicare Advantage or Part D (prescription drug) plans.
Other Key Details to Pay Attention To
There are varying degrees of coverage, with insurance premiums ranging in cost from hundreds of dollars a month for a single-person plan to well over a thousand dollars for a family plan. That doesn’t include deductibles, and the price can go up even higher for all-inclusive coverage.
While it may require making a few phone calls to your insurance provider or HR department, a bit of number crunching, and some dedication to following up, your research will pay off and get you one step closer to success on your family-building journey. Plus, it could save you some major cash, which is often a huge hurdle to achieving your bigger goals.
Insurance Questions to Ask
A detailed list of what to ask your insurance provider to see how far your coverage goes and evaluate your current plan.
What should I do next?
If you are tapping into employer-provided health insurance, you’ll need to ask your human resources department what their particular policy is. Why? Companies set their own dates for open enrollment! It typically falls around the same time as the general open enrollment period, but you should always check with your HR department - just to be safe.
During this time, you can elect to stay on your employer-based health insurance or switch to another provider in the marketplace. You might decide to do this for fertility coverage reasons, which we’ll help you explore below.
It goes without saying, but if you are planning for (or already in the midst of) fertility testing or treatment, it makes sense to have an insurance plan that covers the most services at the lowest possible out-of-pocket cost.
Support is Available
We know dealing with insurance can feel quite daunting, but once you research your options, you'll be able to tackle this open enrollment season feeling more empowered and prepared to achieve your goals.
If you're feeling stressed or unsure of what to do next or where to look for answers, reach out to your HR department, talk to your fertility clinic team, or ask for support from loved ones! You don't have to figure it all out on your own.
5 Open Enrollment Tips for Fertility Patients
While the official deadline for choosing an insurance plan is usually December 15th, don't wait until the night before to start your research, as you'll risk losing your chance to make much-needed adjustments.
We know it can be tempting to put off overwhelming responsibilities like researching your insurance coverage - it's hard to know where to start. That's why we're here to help you break the process down into more manageable tasks.
Here are five important tasks to check off your to-do list before the open enrollment period ends on December 15th:
1. Evaluate Your Current Policy
Even if you think you have a pretty good handle on your current insurance policy, you should always read through it as thoroughly as possible before taking the next step. Let's be honest: it’s not necessarily easy to understand insurance and medical lingo!
Remember: If you're feeling confused, you can always call the insurance company or talk to your employer’s human resources department to request guidance and support.
2. Compare Available Insurance Plans
Your next step is to do some research and compare your current policy against any other available policies. Look to see which fertility tests and treatment pathways (i.e. ovulation induction, IUI, IVF) are covered by each policy, what the lifetime limits are for fertility treatment, and what you're required to do to get approved for treatment.
Did you know? Blood work and fertility tests should always be covered by insurance. Keep this in mind so you don't end up paying thousands when you don’t need to!
Examine the Formulary
A formulary will list out all of the fertility medications that will be covered. Medications are an integral part of most fertility treatment protocols - so this is exceptionally important to know.
Know Your Deductible
Make sure you are familiar with the annual deductible, monthly premium, and any additional payments (such as copays) that must be paid for each doctor's visit, procedure or prescription. Then, balance those expenses against the annual premium to determine which is likely to cost less over the year.
3. Talk to Your Insurance Provider
Another essential part of this process is spending time talking with the insurance provider - and knowing how to ask the right questions. Need help? Check out our helpful list.
4. Use Up Remaining 2024 Coverage
After choosing the right policy to help you cover any needed fertility care in the new year, it's time to determine how much of your annual deductible you have spent for this year.
If you've already reached your deductible, ask your doctor which tests you can check off your list now (while insurance covers more of the costs) to prepare for fertility treatment in 2025.
Did you know? Many fertility test results are reliable for up to six months - so if your insurance will pay for the bulk of them until the end of the policy year, take advantage!
Do you have an FSA or HSA?
If you have a Flexible Spending Account (FSA), a Health Savings Account (HSA), or other medical spending plan, you can also use those savings to pay for any additional costs. The National Institutes of Health (NIH) offers a helpful explanation of the differences between medical spending accounts.
5. Explore Insurance Riders
If none of the policies offered by your employer provide adequate coverage for fertility treatment, it may be possible for you to purchase something called an insurance rider. This can help defray the cost of treatment and make a big difference.
Put simply, an insurance rider adds additional coverage at an additional cost. While it may sound pricier upfront, this option can actually be less expensive than paying out-of-pocket or getting a different healthcare provider.
For those in the LGBTQ+ community, purchasing an insurance rider can sometimes be the best option for getting the family-building assistance they need to move forward.
Note: If you're planning to undergo fertility treatments like intrauterine insemination (IUI) or in vitro fertilization (IVF) in the coming year, the higher premium might be worth it.
Can I do IVF without insurance?
Even if your policy doesn’t fully cover everything you need (or you don't have insurance), there are other options to help you achieve your family-building goals.
Why is fertility coverage so complicated?
Variability in state laws, lack of federal regulation, coverage limitations, and disparities in eligibility criteria (i.e. what you need to prove to 'qualify' for treatment) all contribute to the complex world of fertility insurance coverage.
When combined with the deeply personal nature of infertility and its treatment, these factors create a patchwork system that leaves many individuals without adequate coverage.
Efforts to improve this often depend on advocacy, legislative changes, and employers' willingness to provide inclusive benefits. While strides are being made towards more equitable coverage for all, there is still a long way to go.
Some good news: In 2023, the American Society for Reproductive Medicine (ASRM) announced an updated definition of infertility which experts expect will push insurance companies to expand fertility coverage - making it accessible to more hopeful parents.
Now Is the Best Time to Act
Here's a quick recap of the next steps you should take to ensure you have the right insurance plan to make your dreams of expanding your family a reality:
- Research all of your possible options
- Use the coverage you currently have to its full extent
- Explore whether adding an insurance rider is right for you
Doing this work now is the best gift you can give to your future self. By learning more about insurance, you can get the best medical coverage available to you within your means. It also means you can check off a big, important task before the holidays hit!
Remember to read all the fine print and understand what your options are, because if you wait too long, you might miss your 2025 coverage window. All of this takes time, but will bolster your confidence and help you figure out this major piece of the infertility puzzle.
While insurance is never a fun thing to talk about and waiting to speak to an insurance customer representative on the phone can really test a person’s patience, remember the end goal: your future family. The work you're doing now will all be worth it!
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