Are we parents yet?

The Clements’ IVF Journey

Insurance games September 30, 2008

Filed under: Financials for IVF — Aria @ 4:25 pm

I don’t get it. We are now being told something else. We are now being told that none of the labs are covered at all with out EPO plan and the surgical center isn’t covered at all, so those expenses we were told two weeks ago to pay and submit for reimbursement we’re now being told are out-of-coverage (they weren’t last week, not according to the two people I spoke to then, and they weren’t when speaking with the clinic’s financial person, and Cody was there and I asked him if I hear it wrong and he heard the same thing I did) and won’t be paid or reimbursed at all. Oooookaaaaaaayyyy. We are tired of all the different stories we’re being told.

Luckily next week is open enrollment, so we can change plans. Unfortunately the only Apple plans that cover IVF are through United. But it looks like the Plus PPO (Choice PPO) (there is also a Basic PPO) plans cover more places and more doctors than the EPO (Choice). The cost difference per year is $477 for us both, which we think will more than pay itself off. Office co-pays will go up to $20 from $15, and to $30 from $20 for specialty visits.

Am I’m reading/understanding this correctly?

The terms say:

Plus PPO

Plan-year deductible
In-Network: $300 Individual, $900 Family
Plan benefits are paid after the satisfaction of plan year deductible.
Out-of-Network: $300 Individual, $900 Family
Plan benefits are paid after the satisfaction of plan year deductible.

Coinsurance
In-network: 100% (Plan pays percentage shown after you pay deductible or copay, if applicable)
Out-of-Network: 70% of the UCR (Plan pays percentage shown after you pay deductible or copay, if applicable)

Annual Out-of-pocket Maximum
In-Network: $2,000 Individual, $6,000 Family (excludes copays)
Out-of-Network: –

Infertility
In-Network and Out-of-Network: Covers diagnosis and treatment of an underlying medical condition that causes infertility, including in vitro fertilization (IVF), gamete intrafallopian transfer (GOFT), and zygote intrafallopian transfer (ZIFT); embryo transport; donor ovum and semen and related costs, including collection, preparation, and storage of; and artificial insemination. Prescription medication limited to a separate $5,000 lifetime maximum.

In-network: $30 copay; 50% after deductible up to a $15,000 lifetime maximum
Out-of-Network: 50% of UCR after deductible up to a $15,000 lifetime maximum

EPO

Plan-year deductible
No deductible

Coinsurance
$15 or $20 (specialaist) copay (Plan pays 100% for most eligible charges after you pay copay, if applicable)

Annual Out-of-pocket Maximum
$1,500 Individual, $3,000 Family

Infertility
Covers diagnosis and treatment of an underlying medical condition that causes infertility, including in vitro fertilization (IVF), gamete intrafallopian transfer (GOFT), and zygote intrafallopian transfer (ZIFT); embryo transport; donor ovum and semen and related costs, including collection, preparation, and storage of; and artificial insemination. Prescription medication limited to a separate $5,000 lifetime maximum.

$20 copay; 50% up to a $15,000 lifetime maximum

This is all word-for-word.

Now I’m confused a bit. With the PPO Plus will this mean we pay the first $300 entirely, and then after that deductible, they’ll cover 50% up to an additional $2,000, which is the out-of-pocket, and then they’ll cover 100%? Or is the deductible part of the put-of-pocket? Something else entirely? What are we looking at as our total out-of-pocket (not including copays), $2,000, $2,300, or something else entirely?

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