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Why carve out fertility benefits?

Julie Chavez, VP, Strategy & Alliances
Image of a document and money representing fertility benefits
Oct 7, 2021
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When HR teams consider health benefits for their employees beyond basic insurance, some prefer to expand their existing coverage rather than provide separate, carved-out benefits. While it may seem convenient to have all of your healthcare benefits in one place, fertility benefits are unique. Keeping them carved out can make it easier for your employees to access the care and services they need. Let’s get into a few reasons why dedicated fertility benefits are both more straightforward and more impactful.

More family-forming options

In the majority of healthcare plans, coverage for fertility care is limited. At its most inclusive, fertility coverage through insurance typically only covers infertility. Before employees can access coverage, they need to receive an infertility diagnosis — defined as not getting pregnant after a year of unprotected sex for those under 35 or six months for those over 35. However, medical infertility is not the only reason someone might seek fertility care. For example, many members of the LGBTQ+ community seek out donor-assisted reproduction to start their families. Under most insurance plans, a same-sex female couple, for example, would need to try at-home insemination with donor sperm — at their own out-of-pocket expense — for six to twelve months before accessing additional options through insurance. Single-intending parents also have limited options through traditional insurance coverage. Fertility benefits remove the need for an infertility diagnosis, opening the door for single-intending parents and members of the LGBTQ+ community to access care.

Some states require employers that provide insurance plans to cover fertility treatment, but requirements vary by state, and most have limitations on what and how much they will cover. Insurance may cover services like diagnostic testing for infertility and assisted reproductive technology (ART). However, gestational carrier (GC) services and donor eggs and sperm are not typically covered and are sometimes even explicitly excluded from insurance plans. Gaps in coverage can create a confusing — and costly — experience for those pursuing care. In contrast, fertility benefits are inclusive of all paths to parenthood, not just infertility treatment.

“My husband’s insurance covers fertility treatments, but only if we were using my eggs and his sperm. Because we had to use donor eggs, they considered it to be voluntary, and they wouldn’t cover it,” one woman shared with SELF magazine. “I wrote a six-page letter to the insurance company basically filing an appeal, and they agreed to cover part of the process.”

Fertility benefits can support complex journeys that fall both in and out of what’s typically covered by insurance. Through carved-out fertility benefits, employers can also offer access to services for which insurance codes don’t exist, such as GC services and adoption. Plus, employers can provide access to fertility benefits for all employees — not just those enrolled on the medical plan.

A simplified experience

Even for those with insurance coverage for infertility, with so much variation in what insurance plans will cover, it can be confusing for employees to understand what aspects of care their plan includes and what they will need to pay out-of-pocket. Some fertility clinics and agencies even have financial coordinators dedicated to helping people parse out their plan.

“In the four years it took my husband and me to have a baby, I spent countless hours on the phone with insurance companies, pharmacies, doctor’s office billing departments, and even shipping companies to understand my coverage, its cost, and how to receive what I needed in time for treatment,” writer Amy Klein shared with The New York Times.

With dedicated fertility benefits, paying for care and services tends to be much more straightforward. For example, Carrot members have access to the Carrot Card®, a flexible fertility debit card for employees. Carrot members with the Carrot Card can use it to pay for an exhaustive list of family-forming eligible expenses by simply swiping their card — no need to wait for reimbursement.

The insurance plans contracted with fertility providers frequently change because insurance companies regularly negotiate rates. Sometimes, those rates become so low that a clinic decides to no longer participate in a network. Because Carrot members are considered “cash pay” patients at fertility clinics, they don’t need to worry about their clinic changing or dropping their coverage. Fertility clinics may also charge less when patients pay out-of-pocket compared with their negotiated rate with insurance companies, so their benefit can go farther than an insurance plan could. Cash pay patients also know upfront what their care will cost, so they won’t receive surprise bills, as often happens with insurance. With this system, employers also have more transparency into the actual cost of care.

Deep expertise and care navigation for employees

How to pay and budget for care isn’t the only complex part of seeking fertility care. Whether someone has received an infertility diagnosis or started a donor-assisted reproduction journey, it can be challenging to know where to start. Employees pursuing any path to parenthood benefit from guidance and support that insurance companies typically don’t provide. In addition to financial support, fertility benefits can also include care coordination and clinical guidance. At Carrot, members meet with a Carrot Expert and receive a personalized plan that guides them through their family-forming journey. Importantly, Carrot has clinical management guidelines in place to ensure members pursue the safest care paths for them.

For example, when pursuing IVF, some people assume that transferring multiple embryos in order to have twins or triplets will save money, time, and stress. But pregnancy with multiples raises the risk of complications, including premature birth and low birth rate. In order to support health outcomes, Carrot only allows single embryo transfers (SET) as part of IVF cycles unless medically necessary.

Before a Carrot member even steps foot in a clinic, they have the opportunity to meet with a reproductive endocrinologist (REI) or another expert to help them determine the best path forward for them. Experts can help employees find the right care, including potential alternatives to costly options like IVF (which isn’t always the first place someone wants to or should start). Care coordinators can also help employees find clinics and services near them, including LGBTQ+-friendly and BIPOC providers. For those pursuing journeys like donor-assisted reproduction and adoption, members can access discounts on specialized legal support.

Administrative support for employers

Self-funded employers have the option of making changes to their health insurance program to make it more inclusive, such as by removing the requirement that someone needs an infertility diagnosis to access care. But removing that requirement can create complications regarding how taxes work and whether costs qualify as medical expenses under IRS law. With a dedicated fertility benefit, your vendor can help your HR team navigate the details and remove the administrative burden from your benefits team. For fully-insured employers, fertility benefits that provide care coordination help handle employee questions about their coverage and accessing the services they need, saving HR teams time.

Carved-out fertility benefits might sound complicated, but separating out fertility can make accessing and paying for care less complex for both employees and benefits teams. Interested in learning more about providing fertility benefits to your workforce? Get in touch with us.

Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical advice, diagnosis, or treatment. Carrot Fertility makes no representations or warranties and expressly disclaims any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app.
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