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What will the average California couple spend on infertility and In Vitro Fertilization treatments?

California has an infertility insurance mandate. This means that many first-order infertility treatments cost very little. Patients owe the deductible and co-insurance.

The California mandate does not include IVF. Now couples must pay the entire cost completely out-of-pocket.

Follow this three-part outline to identify options and strategies and afford to bring home a baby.

  • Tips when financing treatments without insurance
  • How success rates and government grants affect spending
  • Estimating unreimbursed expenses with insurance

California Infertility Treatment Costs without Insurance

First, we explore the average costs of infertility and In Vitro Fertilization treatments without insurance. That is the reality for most site visitors concerned about what they must pay out-of-pocket for any assisted reproductive technology.

Infertility Financing

Request an infertility treatment loan. Many California couples find they must pay out-of-pocket for a large portion of the overall costs of their infertility or IVF treatment. The insurance mandate does not cover many common procedures. The borrowed funding helps people get started.

  • Job protections during maternity leave help determine whether the financing is a viable alternative. Financing IVF or any other infertility treatment can lead to hardship if mom loses her job during her pregnancy or after childbirth. If will be very difficult to repay a loan if the family loses a job and access to group health insurance.
  • The state disability program makes borrowing money much safer. When mom becomes pregnant after treatment, she will need to stop working to deliver her baby. The automatic income replacement makes it easier to stay current on the loan repayments. Couples in other states do not have this major advantage.

Insurance Mandate

California does have an infertility mandate. The law requires health insurance plans to offer coverage for “medical procedures consistent with established practices in the treatment of infertility by licensed physicians and surgeons.”

The law has many loopholes. It is important to understand what procedures and which people are not covered. Many plans are exempt from the requirements. You must pay 100% out-of-pocket if you fall into any of these categories.

  • Individuals working for religious employers
  • Residents employed by out-of-state companies
  • People buying plans on the individual market
  • Low-income earners enrolled in the Medi-Cal Medicaid program
  • Employees at groups that decline the offer of infertility coverage

In addition, the two main uncovered procedures are the reversals of voluntary sterilizations, and In Vitro Fertilization.

Sterilization Reversals

The California insurance mandate excludes coverage for the reversal of a voluntary sterilization procedure. This means that prospective parents will have to pay out-of-pocket for a tubal ligation reversal, or vasectomy reversal.

The average out-of-pocket cost of a bilateral tubal ligation reversal surgery in CA is approximately $10,000. This includes the medical testing, surgery, anesthesia, and hospital charges.

The average out-of-pocket cost of a vasectomy reversal surgery in CA ranges from $5,000 to $20,000 depending on the complexity of your procedure. There are two types:

  1. Vasovasostomy – the surgeon sews back together the vas deferens
  2. Vasoepididymostomy – the doctor attaches the vas deferens directly to the epididymis.

Average Cost of In Vitro Fertilization in California

The average total cost of In Vitro Fertilization in California depends on success rates and optional services. You must factor in what you spend per cycle and then multiply by the number of cycles needed to conceive. Therefore, success rates speak directly to total costs.

We address the most popular, but least important topic in this section first – what insurance companies cover IVF in California.

Companies Covering IVF

California does not have an IVF insurance mandate. The California Health and Safety Code Section 1374.55 specifically exclude In Vitro Fertilization from the mandate.

Health insurance companies are not required to cover IVF. Most choose not to because the procedure is not medically necessary, and the success rates are greater than zero. A barren womb does not generate expensive claims for labor and delivery, or twins born premature and confined to the NICU. Successful outcomes do generate these claims.

The lone exception to this rule occurs when a group insurance plan originates in a state with an IVF requirement. Eight states have this rule: Arkansas, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, Rhode Island, and Texas.

California residents working for these out-of-state employers may luck out. Those working for employers headquartered in CA do not benefit.

  • Aetna covers IVF for group plans issued in the 8 mandate states.
  • Anthem Blue Cross operates in 14 states. None requires coverage.
  • Cigna is a nationwide company subject to 8 mandates
  • Kaiser operates only in California and does not cover IVF
  • United Healthcare is also national in scope and subject to 8 mandates

IVF Success Rates

California IVF success rates determine the expected amount a couple may have to spend to bring home a baby. Success rates and total costs are inversely related – as you see from this chart using an average cost of $15,000 per cycle.

Success Rate# of CyclesTotal Cost
25%4$60,000
34%3$45,000
50%2$30,000

As you can see, couples can spend lots of money trying to conceive – with no guarantee of success. The probability of a positive outcome has more to do with the diagnosis and age of the patients than the clinic you choose.

The Society of Asssisted Reproductive Technology (SART) publishes the most comprehensive and reliable set of data to help you determine IVF success rates.

DiagnosisLive Birth Success Rate
Blocked fallopian tubes31%
Diminished ovarian reserve16%
Endometriosis33%
Male factor infertility37%
PCOS39%
AgeSingleton Success Rate
Younger than age 3536%
35 – 3730%
38 – 4020%
41 – 4211%
Older than age 423%

Cost of IVF Procedures

The average cost of IVF in California means nothing to any couple using one or more optional services. Each couple custom tailors the treatment according to their needs. The clinic may recommend various medications, sperm injections, embryo freezing and thawing, and other treatments.

  • Embryo adoption provides a lower-cost alternative for couples with repeated IVF failures. The expenses range from $7,500 – $20,000 and include the agency fee, family evaluation, and frozen embryo transfer.
  • Egg donor compensation ranges from $5,000 to $10,000 plus other charges, which include psychological screening, travel expenses, attorney fees, and genetic counseling.
  • Preimplantation genetic diagnosis (PGD) and gender selection charges run up to $5,000.
    • Embryo biopsy $1,800
    • Chromosomal analysis $3,500

IVF Grants

Both the federal and California state government provide a form of IVF grants. The government grants come in the form of tax savings. The unreimbursed medical expenses are income tax deductible at the federal and state level.

Try to consolidate as many expenses in the calendar year to make the most of these tax-saving grants. You do not begin saving money on taxes until your deductible IVF costs exceed a specified threshold.

  • IRS threshold is 10% of adjusted gross income
  • California threshold is 7.5% of the federal adjusted gross income

California Infertility Treatment Costs with Insurance

Determining the average cost of infertility treatments in California with insurance is a very different exercise. Now we have to examine the expected unreimbursed expenses – the amount left over after the health plan pays the claim.

Each plan has different cost-sharing features and a unique set of in-network and out-of-network providers. We examine artificial insemination and fertility medications to illustrate these concepts.

Artificial Insemination

The average out-of-pocket cost in California for artificial insemination is very low – when you utilize an in-network clinic. When you go out-of-network the costs are much higher.

The infertility insurance mandate includes coverage for artificial insemination. When the clinic is in-network with the plan – the patient pays a predetermined amount. The healthcare plan document will spell out the in-network cost-sharing features.

  • Deductible – the annual amount the patient pays before benefits begin
  • Copayment – the fee the patient pays for each visit
  • Coinsurance – the percentage of allowed charges the patient funds
  • Maximum out-of-pocket – the annual cap on patient in-network charges

If the clinic performing the artificial insemination is out-of-network, expect to pay the difference between the clinic retail prices and the allowed charges. The allowed charges are pre-negotiated rates that out-of-network clinics reject.

Fertility Medications

The average out-of-pocket costs for fertility medications in California are also very low with insurance. The infertility mandate includes coverage for many medications such as Clomid, Menopur, Ovidrel, and Follistim.

Most prescription drug plans employ a tiered reimbursement design. The common formulary tier designs may look something like the following:

  • Tier 1 – Generics with very small copayment
  • Tier 2 – Preferred brands with modest copayment
  • Tier 3 – Non-preferred brands with large copayment

Sources

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