Cycle-based vs. dollar cap fertility benefits

Pregnant couple

How your benefit model affects coverage, outcomes, and member experience

Despite the prevalence of infertility – one in six people globally are affected – disparities in care and coverage are widespread. Studies show Black women are two times more likely to be impacted by infertility, and a third of the time infertility is “male-factor.” And despite outdated, discriminatory policies that often put an infertility diagnosis out of the reach of LGBTQ+ individuals, 63% of those in the LGBTQ+ community who are planning to build families expect to use assisted reproductive technology (ART) or adoption to become parents. 

This often leaves members navigating care alone, if at all, and unfortunately results in poor outcomes and increased healthcare costs for Plans and employers. But even if a Plan or employer has a fertility benefit in place, does it do enough to thwart unnecessary costs? 

Not all fertility benefits are equal. Let’s define the difference.

A best-in-class benefit design is the foundation of an equitable, effective fertility and family building solution – one that delivers better member outcomes and avoids unnecessary costs. But not all fertility solutions meet this criteria. Generally, there are two fertility benefit approaches available in-market: a cycle-based benefit and a dollar-cap lifetime max benefit.  

So, what’s the difference between the two? 

Cycle-based models work by “bundling” all treatment, testing, labs, and other components associated with a course of treatment, making the benefit easier to use and understand. The key to this benefit design is that cycle-based care offers the flexibility to meet all forms and paths to building a family. 

The cycle-based design focuses on end-to-end episodic coverage, empowering patients and their providers to make informed decisions based on their unique needs, and giving patients peace of mind that they won’t run out of coverage in the middle of a treatment. This leads to better care and superior outcomes (because providers can focus on the first, best treatment); reduced stress and improved mental wellbeing for members; and long-term cost savings for health plans and employers because of these improved outcomes.  

By comparison, dollar-cap designs assign the same total lifetime maximum reimbursement amount for each member, ignoring their specific needs, location, and other elements that impact treatment cost. Individuals are also billed separately for each service throughout their treatment journey. That means someone undergoing IVF under a dollar-cap model would have separate claims for a consultation, testing, lab work, and associated procedures that add up quickly against their balance. That same individual with cycle-based coverage would have all of that bundled into a single episode of care.  

The support members deserve; the cost-savings clients need

Now that we understand the main differences between the two models, let’s talk about how these differences impact the coverage, outcomes, and member support available throughout a family building journey. 

1. Coverage and claims

A fertility and family building benefit design that offers comprehensive coverage, including all necessary diagnostic testing, access to the latest technology, medications, and the flexibility to select the best treatment option, provides true benefit equity.   

Because services are bundled in a cycle-based design, the patient can immediately focus on the treatments they need, providing equitable access to care regardless of income, geography, or chosen path to parenthood, and enabling evidence-based care decision to be made, leading to fewer high-risk pregnancies and NICU costs.  

For the payor, comprehensive coverage also limits claims leakage. Progyny has worked with health plans to uncover many instances where treatment components are billed under general medical rather than to fertility care. Why? Because patients and providers with a dollar-cap model are forced to work around the limits of fee-for-service plans. A cycle-based approach helps to solve for claims leakage by incorporating all services. 

2. Member experience

The parenthood journey can be long, time consuming, expensive, and stressful. A best-in-class fertility and family building benefit requires superior member support, but dollar-cap models often leave members siloed, trapped into making care decisions that drive up cost, increase stress, and lead to poor results.  

Dollar-cap plans cause more stress and anxiety because they drive a scarcity mindset – members are required to spend time with billing coordinators, figure out how much services will cost, and keep track of care and cost all on their own. Dollar-based benefits are also inequitable, as different people need different treatments and levels of medication. Some patients may also be able to afford less treatment than others based on where they live, meaning a dollar-limit doesn’t go as far for them. Finally, dollar-based benefits do not treat infertility in the same way we typically treat other complex medical care, which furthers the stigmas associated with fertility care.   

A cycle-based benefit, on the other hand, normalizes care and allows patients to mix and match the treatments they need, ensuring equity across the diverse fertility needs of an employer’s population. And because cycle-based care is often advocate-supported, patients receive dedicated help in navigating everything from care options to billing. 

3. Outcomes

Dollar-cap limits incentivize cost-based care decisions that lead to less-than-ideal member outcomes and higher healthcare costs that could have been avoided had the individual and their provider been making evidence-based care decisions. A Progyny client who had a dollar-cap model in place before working with us saw the impact of this first-hand. Their dollar-cap model came with limitations that put their policy – not the patient and provider – at the center of determining access to care. After changing from a dollar-cap to a cycle-based benefit with Progyny, the client saw zero NICU babies as compared to the 13 NICU instances they covered under their old dollar-cap model.

After changing from a dollar-cap to a cycle-based benefit with Progyny, the client saw zero NICU babies as compared to the 13 NICU instances they covered under their old dollar-cap model. 

Cycle-based designs eliminate this burden, and combined with a large, actively managed network of top clinics and providers like Progyny’s, clients can keep a real-time view on key fertility journey outcomes for every member while holding providers to the highest standard of effective, evidence-based care. At Progyny, we know that this model means members need fewer treatments and less medication to achieve their dreams of growing their family.  

Debunking the dollar-cap

Simply put, dollar-cap plans can create health inequities and be burdensome for members. These models can ultimately increase total cost to the health plans and employers. This inefficient benefit design is often accompanied by poor member experience, lack of medication integration, and limited networks, resulting in suboptimal clinical outcomes and members who aren’t fully supported on their family building journeys. 

A cycle-based benefit helps employers and members overcome the inherent barriers of dollar-cap benefits. For employers, a cycle-based approach ensures that all fertility treatment services are captured under the fertility benefit, and that they are not inadvertently paying fertility claims under medical claims. For members, a cycle-based approach means a supported member experience, less stress, and, most importantly, better clinical outcomes.