Top 8 Tips for Navigating Your Open Enrollment

If you are planning to undergo fertility treatment in the next year, you’re probably already thinking about what it will cost and whether your insurance will cover the bill. If you have an employer who provides coverage for fertility treatment, you’ll want to make sure you make the right choices during open enrollment to maximize the possible benefits you could receive.

If it turns out that none of your employer’s plans cover infertility or the benefit they provide isn’t enough to cover your needs, you’ll want to get more information about financial programs that can help make paying for treatment more affordable.

Delphinia Bellinger has been a financial counselor at Shady Grove Fertility’s Frederick office for the past 15 years. Throughout the year, she fields hundreds of phone calls from patients about their insurance coverage and what options they have when insurance doesn’t pay the bill. She is committed to helping patients afford their treatment with the least amount of stress possible. “We know our patients have enough stress already dealing with infertility,” says Bellinger, “so we do everything we can to alleviate the financial stresses that often times come along with fertility treatment.”

Read Bellinger’s top tips for navigating open enrollment:

Tip 1: Notify SGF as soon as your coverage changes
It is important to notify your financial counselor as soon as your insurance information changes to prevent delays in treatment. It takes time to verify benefits – sometimes several weeks – and we do not want your treatment to be delayed. Please note that the earliest insurance plan changes can be verifed for 2016 is the beginning of January, once your insurance provider has updated its system.

Tip 2: Consider the time required for authorizations
Insurance plans frequently require providers to obtain referrals and prior authorizations on behalf of patients before they can start any course of testing or treatment. These authorizations in some cases can take up to a month to receive and can delay treatment start dates for patients. If you wish to start a treatment cycle in the first few weeks of January with your insurance benefits, our financial team will need to obtain the necessary prior authorizations before you can begin to cycle. Please keep in mind that we must work with – and through – your insurance plan to obtain benefits and authorizations, and there may be delays on their part in processing insurance changes and registering new enrollees.

Tip 3: Get help from your HR department. Benefits are employer-driven
Employers purchase specific benefits and services for their employees. To find out the benefits available to you, request a copy of your benefits summary from your employer. Even if you have the same plan, benefits and out-of-pocket expenses may change from year to year.

“The first step is to obtain a ‘Benefits Summary’ for each insurance plan that is offered from the HR department,” says Bellinger. This document is a quick reference of everything covered by the plan and may list the benefits, deductibles and co-pays related to an infertility diagnosis. Sometimes, however, it does not.

“If infertility isn’t listed on the Benefits Summary or there isn’t enough detail to answer all your questions, you’ll need to contact your HR department or your employer’s benefits coordinator,” says Bellinger. “Calling the insurance company directly usually does not help.” That’s because your employer is the one that chooses the details of the plans they will offer. The customer service team at the insurance company often doesn’t have access to those details until members are subscribed.

Bellinger adds, “HR personnel should have access to all the details of the plans or be able to find out and get back to you.”

Tip 4: Pick the plan that’s best for your family.
We know that picking the right plan can be tough. Shady Grove Fertility has experienced financial counselors at each office who are available to help. “If you are confused about the jargon being used on the policy or need clarification about how a financial program works, please call us,” says Bellinger. “We can’t decide which plan you should join, but we are happy to answer any questions that might make the selection process easier.”

Some patients ask us to help them choose their plan, but unfortunately we can’t. Choosing an insurance plan is a personal choice in which all aspects of your personal and family health needs should be considered. We encourage you to check with your provider or Human Resources team as to what coverage is given under each plan available through your employer.

Tip 5: Ask the right questions
Insurance policies are full of jargon and fine print, but those details can make a big difference in the coverage you receive. For example, some policies will pay to treat underlying medical conditions that cause infertility, but won’t pay for fertility treatments like IUI or IVF. “You have to ask for a number of specifics,” says Bellinger, “so, it’s best to have a checklist handy when you talk with HR.”
The main questions you’ll want to ask are:

Are the initial consultation and diagnostic testing covered?
Is Intrauterine Insemination (IUI) – also called Artificial Insemination – covered?
Is In Vitro Fertilization (IVF) covered?
Is there any coverage for the medications associated with these treatments (sometimes referred to as “injectables”)?
Are pre-existing conditions excluded? If so, what qualifies as pre-existing?
Do we have to meet any special medical criteria to use the benefit?
Is there a maximum benefit amount? Is it a dollar amount or a number of cycles? Is it annual or lifetime? What counts toward the max – diagnostic testing, medications, or just treatments?
Are there deductibles, co-pays and/or co-insurance?
Do we need a referral in order to see a fertility specialist?
Do we need prior authorization for consultation, testing, or treatment?

Tip 6: Be aware that your existing plan may change
Even if your insurance company stays the same, your employer may purchase different benefits affecting your plan for the coming year. Because of rising costs, companies are frequently increasing deductibles and requiring more co-insurance from employees. It’s always a good idea to re-check your benefits even if you think you want to stay on the same plan.

Tip 7: Use an FSA account
To help cover your expenses, it may be beneficial to enroll in a flexible spending account (FSA) if your employer provides one. FSAs are funded with pre-tax money deducted from your paycheck and can be used to pay for medical expenses not paid for by insurance, such as deductibles, co-pays, treatment, and medications. Most companies ask you to set up FSAs during their open enrollment period.

If you decide to enroll, you must satisfy any FSA eligibility requirements and administrative guidelines set up by your employer. It’s important to know health FSAs are monitored by the IRS and are subject to several rules and regulations. One particular rule that impacts patients using an FSA for their treatment is the stipulation that funds cannot be used towards a deposit or when paying for services in advance. When planning the amount of money to add to your FSA, keep in mind that most FSAs are use-it-or-lose-it. Money left in the account at the end of the year often times will not be refunded or rolled over into another account. Participants should be conservative when choosing how much to save in their FSA. For all of these guidelines, please refer to IRS publication 969.

Tip 8: Check out In-Network benefits vs. Out-Of-Network benefits
It’s important to find out if the plans being offered by your employer are accepted by Shady Grove Fertility. You can see a list of the plans we accept here.

Even if none of the plans being offered by your employer are accepted by Shady Grove Fertility, you can still use your benefits if you have an out-of-network option on the plan. Most plans will list benefits for in-network and out-of-network on the Benefits Summary. There may be different rules for using benefits out-of-network and there is usually a higher cost associated with treatment for the patient.

Financial Programs that Can Help

For those who don’t have insurance coverage for treatment, Shady Grove Fertility offers a number of unique financial programs that have helped thousands of patients. In 2013 alone, over 3,200 patients used a Shady Grove Fertility financial program.
These programs include:

Shared Risk 100% Refund Plan: This program provides up to six IVF or donor egg treatment cycles and subsequent frozen embryo cycles. If you do not take a baby home from the hospital, you will receive a 100% refund (some exclusions apply).
Shared Help Discount Program: This program provides a discount on fees for couples making $95,000 or less per year. This discount can be applied to most of the other financial plans.
Multi-Cycle Discount Program: This plan provides a 40% discount off the cost of two IVF cycles and subsequent frozen embryo transfer (FET) cycles for one flat fee paid in advance.
Shared Donor Egg: This program allows donor egg recipients to share the eggs provided by a single donor and also share the costs of treatment.
Military Discount: Active military and reservists receive a 25% discount off self-pay rates for services provided by Shady Grove Fertility.

Additional programs include:

It doesn’t happen often, but occasionally patients are better off using one of Shady Grove Fertility’s financial programs rather than using their insurance benefits. “One example might be if you have a low lifetime max, like $5,000, and medication costs contribute to the max,” says Bellinger. “In that case, it might be better to do the Shared Risk program and use your insurance coverage for medications.”

Knowing your infertility diagnosis will help you to plan for treatment in the coming year. Schedule your appointment today to get your basic infertility work-up started and to work one-on-one with a financial counselor.