Should we consider dropping my employer-sponsored insurance to get coverage for a specific procedure?

Submitted by rvH3Ah8zFtRX t3_124r8zn in personalfinance

My wife and I are in the beginning stages of researching IVF. Basically all we know right now is that it can be very expensive, on the order of $10k per cycle. The good news is that we live in a state (Illinois) which requires that health insurance plans cover it. The bad news is that it's chock full of loopholes. Apparently there's an exception for "self insured" plans (which many large companies do). And also doesn't apply to companies with out of state headquarters (which mine is). And I've also heard that even using a plan administrator based outside of IL can remove the requirement.

So long story short, our plan wouldn't cover it. We currently pay about $325 per month (pre tax) for our coverage. I did a bit of window shopping on healthcare.gov, and found plans that do cover it for around $850 per month (not sure if that would be pre- or post-tax). Some back of the napkin math shows that would be about $7k extra in premiums over 12 months, to possibly save $10k+.

I know I'd need to put the actual plans side-by-side to compare everything else. But at a conceptual level, is this something we should seriously consider doing?

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np20412 t1_je0j96v wrote

A single cycle of IVF is going to cost you more than $10k. Between your consults and mom's testing with the RE, your testing, your sample collection + cryo and/or donor usage requirements, the amount of meds you need, the number of stim cycles you need, etc. The meds alone for one round of stim are $7k+, and that is just the horomone injections. After that there are considerations for costs associated with the lab work to create the embryos, the storage of any embryos that are created that you don't use in the first cycle, genetic testing on any viable 3 or 5 day embryos, prepping mom's body and the actual embryo transfer itself, and lastly anything that may come up in between.

Make sure the plan you choose will cover the PHARMACY part of IVF, that is a significant portion of the cost. The meds are not cheap. Also take into account deductibles and copays/OOP max if not explicitly covered under the ART benefit.

Also know that it might take more than a year so you might be with this secondary plan for longer than just a single year.

Source: IVF in 2019 we had our first consult in January and embryo transfer did not happen until September. Got lucky and only had to do just 1 cycle (18 eggs collected, 6 5-day embryos, only 1 was viable after genetic testing and grading which was implanted and successful). Total cost was close to $20k, including unexpected surgery for my wife to remove some polyps from her uterus before transfer.

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rvH3Ah8zFtRX OP t1_je0miey wrote

Thanks. Honestly I get a bit confused about pharmacy coverage and how that gets intertwined with everything. My wife's plan through her job had a separate pharmacy administrator. My plan at my last company had a pharmacy-specific deductible, while my current plan does not. But maybe that's all irrelevant regarding IVF if infertility treatment isn't broadly covered regardless.

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np20412 t1_je0onvh wrote

The way our plan worked for Pharmacy portion was just that the meds were not covered by the normal pharmacy benefit at all, the claim was denied, but then the cost was picked up by the fertility/ART benefit. My plan offered $7500 worth of lifetime coverage for prescription drugs as part of IVF and we blew past it in the first cycle (total cost was around $9k for meds, so $1.5k out of pocket for us). You just will want to make sure the infertility benefit will cover the pharmacy portion, if the pharmacy part of the plan itself isn't offering coverage for fertility medication.

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meamemg t1_je0gua8 wrote

Maybe. To make sure, are you looking at the full price of the plan on healthcare.gov or a subsidized amount based on your income? If you are eligible for a plan through work you are inelligible for a subsidy. Also, keep in mind you can only get the plans during open enrollment at the start of each year unless you have a qualifying event.

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rvH3Ah8zFtRX OP t1_je0m6b5 wrote

Yep, I clicked through their menus and it told me I was ineligible for the subsidy, and that enrollment doesn't open up again until January. So just doing some due diligence right now.

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HighOnGoofballs t1_je0ikfd wrote

Did you also check deductibles, out of pocket max, copays, and how it provides for pregnancy? Can you use the same doctors you do now? You can’t just jump back on your employers once you’re pregnant btw. $850 also seems kinda low for two people without subsidies. And open enrollment is closed too

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rvH3Ah8zFtRX OP t1_je0m9ld wrote

Right, that's why I said

>I know I'd need to put the actual plans side-by-side to compare everything else.

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bros402 t1_je0mmt6 wrote

$850 sounds low for a couple - are you just putting your wife on marketplace insurance?

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rvH3Ah8zFtRX OP t1_je0n8uc wrote

I put both of us in. The price shown didn't say "per person" so I assumed it was our total, but I guess it's possible it wasn't.

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bros402 t1_je0rig9 wrote

yeah that is your total

you might want to check what it is as a family for when you have a kid

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np20412 t1_je0x170 wrote

when they have a kid it would be a qualifying event and they can switch back to employer plans

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bros402 t1_je0yc3a wrote

well yeah - but it is worth seeing the cost for employer insurance v. marketplace plan for family, along with the networks

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