It’s that time of year again – open enrollment for your employee benefits! As you review your benefits guides and tune into your company’s webinars, you and your colleagues may hear about fertility and family building benefits.
According to a 2023 study, 40% of US employers now offer some sort of family building coverage, and research shows 64% of these companies have done so because an employee asked for it. Which leads us to an important point – your voice matters! When you ask, your benefits leaders listen.
Insurance plans and their coverage nuances can be tricky to fully understand, especially when trying to work out if, and how, fertility treatment is covered. Here are three key questions to ask your benefits team this open enrollment season to help you better understand any coverage gaps your fertility benefit may have and highlight the areas of improvement you can ask your benefits team to consider addressing.
1. What kind of fertility benefit plan design do I have?
It’s important to know more about how your plan design could impact what’s covered, and how it’s covered, throughout your family building journey. Here are three question you can ask to better understand your plan design:
- What’s covered? There are many medical and diagnostic components that take place during a fertility journey. Unfortunately, because of the way fertility has been traditionally covered, there are many instances when basic and necessary components of treatment aren’t covered under a benefit – forcing some to make financial-based rather than clinician-recommended health decisions. Genetic testing of embryos during the IVF process is a great example. Since this testing is often not covered under traditional fertility benefits, some may opt out, leading to adverse effects on a future pregnancy or the health of the baby.
A fertility and family building benefit 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 peace of mind for patients embarking on this journey. - Is everybody covered equally? Because of outdated coverage policies, there are many times when individuals who do not fit the heteronormative definition of infertility (6-12 months of unprotected sex) cannot access their family building coverage. Single parents by choice or those in an LGBTQ+ relationship have the risk of being locked out of their fertility and family building coverage if the benefit design is not equitable. In fact, Progyny’s recent LGBTQ+ survey found that 68% of individuals surveyed were locked out of their coverage due to policies in place that were unwittingly discriminatory.
It’s important to ask questions that ensure your family building benefit supports all paths to parenthood. - What type of plan do I have? 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 treatments, tests, labs, and other components associated with a course of care, making the benefit easier to use, understand and ultimately ensure no other factors (path to parenthood, location, etc.) play a part in how much you pay out of pocket and how much is covered. By comparison, dollar-cap designs assign the same total lifetime maximum reimbursement amount for each patient, ignoring their specific needs, location, and other elements that impact treatment cost.
2. How many high-quality clinics/providers do I have available near me?
Best-in-class benefits will have robust, curated and credentialed networks of fertility specialists, including reproductive urologists for male infertility support. Some benefits may even support prioritized appointment scheduling with providers in your area. Understanding the provider access your benefit offers can provide some peace of mind during an often-stressful time.
When analyzing your family building benefits, ask about the number of clinics/providers you’ll have access to within your network. You can also ask for more information about the standards used to include providers in the network. You’ll want to make sure you have a choice of high-quality providers that are convenient to where you live and work, as a typical fertility journey will have as many as five to ten appointments during active treatment times.
3. What kind of patient support will I have?
The family building journey can be complex and stressful. In fact, a recent patient experience survey found that 65% of respondents found the payment and insurance authorization process of their coverage was complex and time consuming. That same survey also found that individuals found it difficult to understand what was covered, with 67% of respondents saying they spent more time than expected trying to understand their benefit.
Having support through even just some of the journey can make all the difference. Understanding the full scope of member support offered through your benefit can help you navigate available resources and get answers to the questions you have – from what paths to parenthood are covered, to helping you feel prepared at upcoming appointments, to answering questions around reimbursement.
While benefits are known to offer varying degrees of support throughout the journey, the best practice is for a benefit to provide dedicated, 1:1 support to patients/employees, coaching them through their initial options, ensuring they understand how their coverage works and can point them to the right resources through every phase of their journey, and into parenthood.
Your voice can make all the difference
Use this open enrollment season as an opportunity to get to know your fertility and family building benefit. If your benefit isn’t providing you the best access, coverage and support possible, your powerful questions could make a difference in getting the right benefit in place. And while benefits decisions can take time to be implemented, remember, 64% of companies who added or made updates to their fertility benefits, did so because an employee asked. Your voice matters!
Visit Progyny.com/TalkToHR for more resources on how to advocate for the right family building benefit for you and your colleagues. You can also sign up on the page for regular updates and additional resources to help you navigate the conversations ahead.