Finance Guides

Cost of IVF with Insurance

Understanding your deductible, co-insurance, max out-of-pocket and what that means for what you’ll pay
Woman sitting frustrated in front of her laptop
Woman sitting frustrated in front of her laptop
You found out that your medical plan covers infertility treatments, yay! You’ve called your insurance plan and made sure that both your provider and your treatment are covered, they said they are.

Ok perfect so your insurance will pay, but just how much will they pay? Probably not all of it.

Don’t make the common mistake of having to call your insurance months after your IVF cycle is completed saying:

"If it was covered then why do I have a bill to pay?!" 😩

A lot of people can get tripped up by insurance jargon and the word covered is probably the most notorious. If you understand what this word actually means, you can set your expectations correctly. 

When a service is covered by your health plan, that means your plan is prepared to pay, but you've got some money to pay too. In health insurance, there's usually a 'cost-share' between the insurance company and you.

Ever heard of a deductible? This is something you have to pay when insurance is covering treatment for you. In addition to the deductible you will probably also pay some co-insurance. 

It’s important to understand what these words mean because they dictate what you will pay to insurance when the cover treatment. 

For most plans, there are three main terms you need to look out for: 
  • deductible
  • co-insurance
  • max out-of-pocket

Some people might have copays but it’s less common for infertility procedures.

Keep in mind that if a treatment is not covered by insurance, then you pay the entire bill yourself, so your health plan's deductible and co-insurance won't be involved at all.

Covered treatments get applied to your deductible, co-insurance, and max out-of-pocket. Non-covered treatments do not.

Ok so let's understand what you'll pay based on your health plan's numbers. 

Deductible 


Your medical plan likely has a deductible on it and it's important to know what the dollar amount is, because you pay that. 

Deductible: The amount of money you have to pay first for covered services before your insurance plan starts to pay anything. 

Your deductible could be $200 or even $2,000 depending on your plan. 

There are a couple of factors that cause a plan to have a higher deductible, one is choosing an HDHP plan and another could be that you have a family plan with multiple people (spouse, partner, children) being covered under your health insurance. 

If you'll be using IVF insurance coverage, be prepared to pay up to your deductible quickly. 

The deductible has to be paid each plan year in which insurance covers services for you. So you only pay your deductible once a year. 

Once you've paid your deductible amount for the year, you're done with that number. Then you move on to co-insurance to see how much you pay your insurance plan. 

Co-insurance


This part always looks tricky on plans but it's really not! Keep in mind that this is not a copay in which there's a flat fee like $20 each visit. This is actually a percentage of treatment cost that you pay. 

Co-Insurance: The percentage of each bill that you will pay once your deductible has been met. Usually you pay a small portion of the bill (e.g. 20%) and your insurance pays the rest (e.g. 80%).

Once you've paid your entire deductible, insurance starts to pay a part of your bills! 🎉  

This is where a 'cost-share' between you and insurance comes in, known as co-insurance.

Now for any bills that come along, you will pay a small percentage of each bill and your insurance plan pays the remaining amount due to the clinic. 

The percent amount varies based on the plan but most commonly, you'd pay 10% or 20% of the treatment cost and insurance pays the rest. Your health plan details will list what your co-insurance is and you can always ask specifically for infertility.  

Do I have to pay co-insurance forever? 😩

Usually no but it depends on how your plan works! 

For most plans, you'll continue to pay co-insurance for each bill that your insurance plan is covering until you've met your max out-of-pocket for the plan year.

Max out-of-pocket


The light at the end of the tunnel! This is the limit for the amount of money you will pay in a plan year for treatment covered by your medical plan. 

This is an important number to be aware of. Also, a nice thing to know is that the amounts you paid to your deductible and co-insurance al apply to meeting your max out-of-pocket. 

Max Out-of-pocket: The maximum amount of money that you will pay for covered services in a plan year. Once you have paid up to your max out-of-pocket on your plan, then insurance starts to pay 100% of the bill for your covered services.

If you're still confused by insurance and numbers aren't your thing, then the only number you should pay attention to is the max out-of-pocket. Once you've hit this number, you're done paying!

Keep in mind that you need to ask your insurance plan whether your IVF coverage specifically applies to a max out-of-pocket and find out exactly what that number is. 

Some insurance plans have special rules for whether certain types of coverage does have a max. 

For example, you might have a $3,000 max out-of-pocket on your plan.

Throughout the year, you get bills from insurance for what you owe to your deductible and co-insurance. Once all these little payments total $3,000 then you've met your max out-of-pocket! 

After that, you'll just get statements showing that you owe $0 because your insurance is paying the full amount for your bills now. 

Depending on how expensive your treatments are, paying up to your max out-of-pocket can be a gradual process throughout the year or sometimes you can meet your max out-of-pocket from just one treatment if it's expensive enough.

Copays


You're not likely to have very many copays when undergoing IVF or IUI but it's good to be aware of these anyway. Some plans do work through copays instead of co-insurance. These are flat fees instead of you paying a percentage of each bill. 

Copays: Copays are set dollar amounts that you pay for a service, like how you might have a $20 copay when you go in for an office visit with your doctor.

The cost of IVF with insurance: How to calculate what you'll pay


Ok, let's do some examples!

We'll use common numbers for a health plan deductible, co-insurance and max out-of-pocket. You can sub your own numbers in for your medical plan details!

Keep in mind the numbers we’ll use are estimates and your clinic may have a different rate for treatment costs.

These scenarios also assume that your provider is in-network and that you have IVF coverage for your entire treatment. 

Here’s your example plan:

Deductible: $500 / Co-insurance: 20% / Max out-of-pocket: $2,000

Example 1


Cheat mode

Just look at your max out-of-pocket!

In this example, your max out-of-pocket is $2,000. This is the amount of money you should expect to pay overall for everything covered under your infertility treatment.

Then your health plans pays the rest because once you meet your max out-of-pocket, your covered services are paid by your insurance plan at 100% for the rest of the year!

Step-by-step calculation

You undergo an IUI cycle and your clinic charges your medical plan $1,100.

You haven’t met any of your deductible yet this year, so your IUI charge will apply to that first. 

So first you'll pay the $500 deductible. Now your deductible has been met for the year!

But theres still $600 left on that bill. Now that applies to your co-insurance. 

So of the remaining $600, you will pay 20% of the amount, which is $120.

In total, your bill for the $1,100 IUI will be $620 because you paid your entire deductible and co-insurance. Your medical plan pays the remaining $480 left on the bill. 

This may seem like you pay a lot but remember that you are now done paying your deductible for the year. 

If you have any further treatment covered that year, you will only pay co-insurance (20% of the bill) until you've met your max out-of-pocket. 

So far, you have already paid $620 towards your $2,000 max out-of-pocket, so you have $1,380 left to go for the year. 

Let's say you need to do a second IUI that year. 

You have already met your deductible so this next charge will just apply to co-insurance. Your clinic charges another $1,100 for this new IUI cycle. 

So your bill is 20% of the charge, which is $220. Your health plan pays the rest, which is $880. 

Now you've paid a little bit more toward your max out-of-pocket for the year. Overall, you have paid $620 for your first IUI and $220 for your second IUI, so you have $1,160 remaining for your max out-of-pocket to go. 

If you have any further treatment that year, you'll continue to pay co-insurance until you've whittled down your max out-of-pocket to 0. Then your insurance plan will start to pay all of the bill. 

Keep in mind that once your medical plan year starts over again, your deductible and max out-of-pocket reset and you start paying your deductible amount and up to your max all over again. Most plans reset on January 1 but some reset at weird times of the year instead, so make sure you know when your plan resets.

Example 2 


New scenario!

Let’s reset and pretend like you haven’t used your insurance this year or done any treatment. You decide it’s time to take control of your fertility and freeze your eggs. 

This is a pricey treatment that often is not covered so it is good if your plan does cover this service. 

Your clinic charges $10,000 to your insurance for the egg freezing cycle. 

You pay your deductible first, so $500.

On the remaining $9,500 balance, you pay co-insurance, which is 20% of the remaining bill.

But wait!

If you pay your $500 deductible and 20% of the remaining $9,500, that would mean you would have to pay $2400. That would send you way over your max out-of-pocket limit of $2,000.

So instead, your insurance plan will cut off your amount due to just be your max out-of-pocket limit. So your bill for the egg freezing cycle would just be $2,000. Your insurance plan would pay the rest of the bill.

So you just paid your max out-of-pocket for the year already! If you did any further treatment that year covered by your plan, your insurance would pay the entire bill.


That's how it's done!

You can do these same calculations for any covered treatment you're planning on. If you’re preparing financially for IVF or an FET cycle and you're not sure what your clinic will charge, you can estimate a charge of around $18,000 for IVF and an average of $5,000 for an FET.

As you can see, even if you have infertility coverage, you'll still be paying some bills so feel free to check out our tips on saving for IVF

This varies a lot depending on the clinic and which procedures are needed. 

Ok, so these are the basics of understanding how medical plans apply cost to a patient and how to estimate ahead of time what you might pay.

Do keep in mind that if your health plan does not cover a specific procedure, like PGT-A for example, then this charge will have to be paid in full by you. The amount you pay for this will not apply to help you meet your deductible or your max out-of-pocket.

If you do plan on paying for PGS/ PGT-A, check out the cost of PGT-A in our article.

Only services that are covered by insurance can apply to your deductible and max out-of-pocket. 

Does your insurance plan cover infertility and has navigating coverage ever tripped you up?

🕵️‍♀️ Ready to get started with a fertility clinic? Head to our fertility clinic search to compare options in your area & learn more about each provider.