Help me understand IVF insurance/should I wait for open enrollment?

[Anonymous]

Hi all - I am 34 with unexplained infertility. Did a few IUIs, have had a few chemicals, and am now thinking of moving on to IVF. We might start IVF in August, paying out of pocket. However, I am a fed and could switch insurance to Aetna or MDIPA at open enrollment (Jan. 1). If I did that, I think one of them will pay half the costs plus meds, and the other requires 6 IUIs first which is crazy and there's no way I'm doing that. I think I'd also have to get a referral from a primary care provider which is doable but annoying.

I really, really want to start now and sign up for shared risk, but I am worried that I am foolishly wasting money if I could get insurance to cover some. SG has quoted me $16,000 for shared risk (6 cycles), plus meds would be more, plus ICSI and assisted hatching or PGS is more if we would need it.

What would you do -- go for it now, or wait? We have the money to do it now, but our retirement accounts would take a little hit, I guess. Am I right in assuming that insurance would cover $8,000 for shared risk and all meds?

TIA!

[Anonymous]

It really depends how important it is to you.

If it were me, you are 34 so time isn't ticking too hard so I would wait for insurance. But do realize, you won't actually be able to start Jan 1. SG won't submit authorizations for cycle approval until after the beginning of the year so you're looking at late Jan into February at the earliest.

Another thing to consider is that shared risk covers freezing of any embryos. We had insurance and Aetna does not pay for that, we were quoted $1800+ for freezing and storage the first year. Shared risk also covers FET's, which would be an additional charge (or OOP cost) with insurance. However, SG says only 1/3 of couples have embryos worth freezing so it may be a non-issue.

[Anonymous]

BTW I don't think you can do shared risk WITH insurance. It's one or the other.

[Anonymous]

I would wait without question . In the meantime have current insurance pay for some more iui's

[Anonymous]

You cannot do shared risk with insurance with SGF. It depends on your financial situation. If you can afford it, I would do shared risk as by the end of the year, if you remain unsuccessful, you can always quit shared risk and get your money back and switch insurance for next year.

[Anonymous]

OP here - I didn't realize that insurance wouldn't cover shared risk. Good to know and that changes a lot... if one IUI cycle is $9500 and I have to pay half, that means after 4 cycles I'd have paid about the same as shared risk ($16,000) out of pocket. Plus it sounds like more for freezing embryos, should we be so lucky.

I definitely don't want to do any more IUIs. They seem like a waste of time. Also we paid for those out of pocket - $1600 a pop.

[Anonymous]

Shared risk can give you peace of mind.
I did 3 IVFs at Shady Grove with federal MD IPA ( the coverage for meds is far better than Aetna). The out of pocket costs for freezing are $1800 per cycle, not covered by insurance. If you need PGD, the fees for testing and embryo biopsy are also out of pocket, around $4000 per cycle. And an FET will count as one of your 3 attempts, unless you choose to pay for it out of pocket ($4600) and save your fresh tries.
Of course hopefully you will be lucky and succeed on the first go, so weigh your options accordingly.
Good luck!

[Anonymous]

OP, I switched to the fed MDIPA this year for fertility. The referral and pre-authorization didn't really add much time to the process. Maybe a month?
If you consider out of pocket, meds add up quick. I was on relatively low dose stims, but my total meds bill was over $6000 (I paid $300 thanks to insurance).
You are young and thus have the luxury of time, so waiting 6 months isnt the worst.

[Anonymous]

Anonymous wrote:You cannot do shared risk with insurance with SGF. It depends on your financial situation. If you can afford it, I would do shared risk as by the end of the year, if you remain unsuccessful, you can always quit shared risk and get your money back and switch insurance for next year.

I second this course of action! It's the best way to have both worlds. If you get pregnant before the end of the year with Shared Risk - yay. But also know that if you wanted to try for another child down the road, you could still time it so you signed up for insurance ahead of cycling and not have to do Shared Risk again. You would still have 3 tries with either Aetna or MDIPA. Also, if you have any frozens left, SGF has a really reasonable rate for FETs with Aetna insurance.