Open Enrollment and Fertility Planning for 2022

The decision to have a baby is a happy one, including for those who may need medical assistance to get pregnant.

Fertility treatment does require extra planning and, sometimes, out-of-pocket expenses. But the more information you have about insurance and other financial resources, the more likely you can keep costs as affordable as possible.

If you are thinking of starting a family in 2022, now is the time to begin planning for how to get the most from all of your resources. Remember, you are your strongest advocate. Read the laws and regulations in your state, understand your insurance coverage, and make sure your health care providers give clear answers to your questions.

Here are some steps that might help you manage the journey you are about to take.

1. Choose the Right Insurer for Your Family

The company you work for is required to offer “open enrollment” for the insurance plans that cover employees and their families. Open enrollment usually begins on Nov. 1 and ends on Dec. 15, so now is the time to review your employer’s plan offerings, ask questions, add family members, upgrade your plan or even change medical insurers.

The open enrollment period is usually the only chance to make changes each year (with few exceptions like changing jobs or getting married). Watch company webinars or attend on-site meetings with insurance providers and/or your Benefits Administrator. Ask questions about what the plans offer, obtain and read a copy yourself, and determine specifically what the plan covers for fertility treatments.

Insurance Plans Can Differ from State to State

Connecticut law requires most insurance companies to cover infertility diagnosis and treatment, including up to four cycles of ovulation induction, a maximum of three intrauterine insemination (IUI) cycles, and up to two in vitro fertilization (IVF) treatments. The Connecticut State Mandate requirements do not apply to employees in self-funded insured plans or to employees who work for certain religious groups.

New York requires private health insurance plans to cover the diagnosis and treatment of infertility for patients between the ages of 21 and 44 who have been covered under the policy for at least 12 months. However, several procedures, including IVF, are excluded.

Insurance providers who work with Reproductive Medicine Associates in Connecticut and New York.

Laws in 13 other states -- Arkansas, California, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, Ohio, Rhode Island, Texas, and West Virginia -- require insurance companies to cover or offer coverage for infertility diagnosis and treatment.

Some companies self-fund their insurance, which means they don’t have to follow state mandates on fertility coverage. You may be able to purchase a rider to the insurance policy that will pay for some or all fertility treatment expenses not covered in your plan, whether it is self-funded or not.

2. Ask Your Insurer These Infertility Coverage Questions

Here are some questions to ask in order to understand the limits of your insurance coverage.

Criteria that need to be met before accessing coverage:

- Are there diagnostic or testing requirements?
- Is IUI required before IVF? Will coverage include treatment for ovulation induction? Use of donor eggs or sperm? Surrogacy?
- What, if any, deductible must be met before reimbursement kicks in?
- Which state’s laws apply to your employer’s insurance contract? If you work in Connecticut, it may be a New York policy, for example.
- Make sure you understand how the company defines “unlimited.” It may mean that the treatment is deemed medically necessary, and you may need your medical team to advocate for you.
Maximums
- What is the maximum lifetime amount that will be covered?
- Are medications included in the lifetime max?
Deductibles
- Is there a pharmacy deductible?
- What medical services go toward meeting deductibles?
- How do out-of-network services affect the deductible?

Learn how to work with your insurance carrier. The relationship need not be adversarial, but patients sometimes must be persistent before they receive answers that are accurate to their specific situations. Call your insurance representative as often as you need to when you have questions. Check your billing statement and Explanation of Benefit (EOB) documents to make sure they are correct.

Download our eBook on how to work with your insurance company to plan for fertility treatment!

In Connecticut, you can exhaust mandated coverage on a policy, and then switch policies to gain additional coverage. Your new carrier cannot claim a “look back” under previous policies in order to exclude procedures.

3. Get Next Year’s Work-Up Done This Year

In addition to making your coverage decisions during the open enrollment period, take advantage of any savings that might present themselves at the end of the year. If you have met your deductibles, for example, schedule diagnostic tests. Your fertility practice can rely on them for up to the next six to 12 months as your treatment begins.

Schedule tests before your deductible kicks in next year.

The same is true if you have a flexible health spending account or a Health Reimbursement Account (HRA) through your employer. Unspent amounts up to a specified limit often can be rolled over to the next year, but now is the time to check how much you have spent so far, and more importantly, what is remaining. Different types of plans, such as health reimbursement accounts or health savings accounts, have different rules. Your employer’s Human Resources department can help you determine what plans are available, how to set them up, how much money you can put in them and what kind of tax benefits they may bring you.

When you have unresolved disagreements with your insurance company, your state’s health care advocate may be able to intervene on your behalf. In Connecticut, visit the Office of Health Care Advocate. In New York, it is the New York Health Care Bureau.

RMA of Connecticut is here to make pregnancy and family building as successful as possible. Our outcomes exceed the national average because our team of doctors and other health care professionals work with financial and support staff to ensure all details are addressed. So get started understanding your insurance coverage, and contact us for help understanding all your options.

Start Now to Prepare for Fertility Treatment in 2022

Start Your Journey