When we asked you how to improve Get Rich Slowly, you told us you’d like an article on “The horrible, terrible, no good, very bad reality of paying for fertility treatments.” We can’t fit all of that into one post, but we did ask Joanna Lahey, who gave us a series on health insurance, to give a broad overview of the issue in this guest post.

Joanna Lahey is an associate economics professor at the George H. W. Bush School of Government and Public Service and a faculty research fellow at the National Bureau of Economic Research. The opinions expressed in this post do not necessarily reflect those of the aforementioned institutions.

When I found out I suffered from infertility, I was lucky enough to be living in Massachusetts and was covered by a Massachusetts health insurance plan. Lucky because Massachusetts is one of the few states in the United States that mandates coverage of infertility treatment. Every test my husband and I went through and every treatment I underwent was completely covered by my insurance. After a year and a half of poking and prodding and medication and monitoring, I knew exactly what was wrong with me. My doctors were able to give the most conservative treatment options so I wouldn’t have to worry about risks with names like “overstimulation” or “rupture” or “triplets.” My only out-of-pocket costs were for HPT, OPK, and a fancy thermometer. [1]

That’s not the situation here in Texas, where it is mandated that infertility treatment be “offered” but not “covered.” What that means is that group insurers must offer at least one plan that has infertility treatment coverage as an option (at any price) and the employer may choose that plan or may choose another (usually less expensive) plan. What that almost always means is that insurers choose the less expensive plan that does not cover infertility. For the most part, people in Texas pay out of pocket for infertility treatment.

The Resolve website has a full listing of the states that mandate “coverage” or “offering” of infertility treatment for health insurance. Even if you live in one of the states that mandates coverage, you may still not be covered. State health insurance mandates do not cover firms that self-insure, so large companies (if they do not buy health insurance from an outside provider like Blue Cross/Blue Shield) don’t have to offer infertility coverage if they don’t want to. In some cases small firms are exempt from state mandates as well. Some states only require that HMOs cover infertility treatment. Some states put age limits on who can use the coverage or limit to specific treatments in their coverage. Even if you live in a covered state, the best thing to do is to check your employer’s plan to see what is and is not covered and what the rules are for that coverage before starting treatment.

How much does treatment cost?

As with all medical expenses, cost is going to vary tremendously with what the specific condition is, how intensive your treatment is, and where you live. In the case of infertility treatment, it also matters how much you can pay and who pays. That’s because if you can afford it or if someone else is paying, you may move to more intensive (read: expensive) treatments faster, whereas if you’re paying out of pocket and don’t have the money, you may wait and try less intensive treatments longer.

Sometimes insurance companies will cover parts of infertility treatments even if they don’t cover infertility. In general, if the diagnosis or treatment fixes a problem that’s not infertility, they are more likely to cover it, even if fertility is a side effect of the treatment. They may cover procedures that diagnose or treat endometriosis or amenorrhea. They may cover various surgeries. They may cover some medications but not others. They almost always cover medications related to thyroid, polycystic ovary syndrome (PCOS), or diabetes, even if those medications may result in your becoming pregnant. The important thing is that the doctor’s office codes the treatment with the non-infertility-related code if one is applicable (so coded as “amenorrhea” if the problem is you’re not cycling, rather than “infertility”). Most doctors’ offices are good about this, but it’s something to ask about just in case.

For ovulation stimulation, the first-line treatment is generally Clomid. Clomid itself is not very expensive — it’s generic and you can generally get it for under $30/prescription (note: all costs are for the U.S.). Doctors often recommend 4-D ultrasound (u/s) monitoring with Clomid, and monitoring costs can get up into the upper hundreds to low thousands, depending on how much your clinic charges for u/s. Another popular drug for ovulation stimulation is Femera (note that this is an off-label use of an anti-cancer drug). This drug is more expensive than Clomid. If your insurance covers it, you only pay your co-pay; but if not, the cost is usually somewhere in the lower hundreds of dollars. These medications are sometimes combined with Intrauterine Insemination (IUI), which can cost from a few hundred dollars to the low thousands of dollars.

The most expensive Artificial Reproductive Technology (ART) treatments are In Vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT). Costs for these procedures are generally $10,000 to $15,000 or more. When discussing these costs with your doctor, it is important to ask whether the medications for ART are included in the transfer cost or if they are an additional $3,000 to 6,000 in expenses. Additional costs will occur if you need to move to using donor sperm, donor eggs, or donor embryos. Genetic testing adds additional layers of cost, though these are often covered by insurance.

The direct costs of fertility treatment aren’t the only costs that you should be considering. Estimates of the cost of infertility treatment per live birth range from $38,000 to $800,000. That top number includes the increased costs of birth complications and multiple births, both of which are more likely with fertility treatment. Once the baby has been conceived, most insurance will cover these costs — but you should look at your individual coverage to see what your out-of-pocket expenditures will be assuming these scenarios. Additionally, according to one study by Stanford University medical professor Michael Eisenberg and colleagues, infertile women seeking treatment spend a median of 51.5 hours on infertility-related activities over an 18-month period. Those hours aren’t consecutive, so you can’t just take a week-long vacation to get it over with. (Obviously, having a baby takes time too, but that’s true whether or not you use infertility treatment!)

Are there ways to lower the costs?

There are some ways that the costs of infertility treatment can be lowered. If your medical costs are more than 10 percent of your gross income, you can deduct the additional amounts on your taxes. That may also be something to think about as you time your more expensive treatments.

If you have to pay out of pocket, you can shop around for drug providers since different pharmacies often have widely varying costs. You can even shop around for sperm if you need it. Different reproductive clinics will also offer a variety of “deals” on fertility packages, but whether or not those are good deals is too complicated to address in this rather lengthy article. Another way to potentially save money is to get enrolled in a clinical trial. These trials will often pay for some or all of your expenses; but you generally don’t know if you’re in the treatment group or the control group — and if you’re in the treatment group, it could be the next amazing intervention or it may not work at all.

Is infertility treatment worth going into debt over?

Personally, having experienced the heartbreak of infertility and the joy of a much-desired child (or two!), I would lean toward “yes” in many cases. However, in an ideal world, you wouldn’t have to debt-finance infertility treatment even if insurance doesn’t pay for it.

When someone reaches that third stage of personal finance, doesn’t want to stop working, and wonders what’s the point of saving more, I always tell him or her to keep saving because unexpected expenses and opportunities will find you. Infertility treatment is one of those potential unexpected expenses. Being able to take the stress of debt-financing out of the equation because you’ve saved for a rainy day means one fewer stressor to deal with during a very stressful time. And it leaves you in a much better position if and when you bring home your bundle(s) of joy.

[1] For the uninitiated: HPT = pregnancy test and OPK = ovulation predictor test, which is kind of like a pregnancy test except there’s always two lines. The second line gets darker when you ovulate. Fun times.

This article is about Health & Fitness, Insurance, Kids

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This article is by staff writer Holly Johnson.

I just sat down to write this post a moment ago and literally stared at the screen for twenty minutes. I’m still ready to bolt out the door at a second’s notice, if needed, and the tears won’t stop rolling down my face.

But thankfully, these are good tears.

My mother told me I might feel this way on my daughter’s first day of kindergarten. Like it or not, the little person I gave birth to five years ago is no longer a baby, but a little girl.

A fearless little girl.

I looked into her eyes this morning and told her how much I loved her.

“I’m so proud of you,” I said, with tears in my eyes and a knot in my stomach.

“Stop worrying, momma,” she said.

“You know I can’t,” was all I could say as she beamed with excitement for her first day at school. Then the bus turned the corner and she smiled and took off without a care in the world.

Moments later, she was gone.

I’m so happy for her, but I’m also afraid. At home, I can keep her safe. I can protect her. But at school, she’s on her own — left to navigate a big, scary world without my help.

As a worrier, I also think a lot about what happens next — maybe too much. Her school career may have just started today; but we all know that, just like the last one, this chapter also has an end. And when that day comes, I will no longer have a kindergartener, but an 18-year-old young adult. I’ve been around long enough to know that it will be here before I know it. And as I plan for her future, I often wonder, “Am I doing enough?”

The growing costs of a college education

My oldest daughter was born in 2009 — a year when the average cost for an education at a four-year college or university came in at around $21,093 in today’s dollars. And now, just five years later, College Board statistics show that the costs of a four-year-degree skyrocketed to an average of $30,336 for the 2013-14 school year.

But these huge tuition rate increases aren’t exactly a new trend. A recent Bloomberg chart-of-the-day shows that the average costs of higher education have exploded over 500 percent since 1985 — the exact year I turned five-years-old. To put that number into context, medical costs grew 286 percent and the consumer price index increased 121 percent during the same time period. In other words, college costs grew faster than almost anything else.

But all of that is out of my control. Try as I might, there is literally nothing I can do to keep spiraling tuition fees in check, or ensure that a college degree is within her reach when she comes of age. When it comes to the cost of college, I can only watch in despair as the news goes from bad to worse.

But I do have some control on my end. I can do what I do best, which is to save, save, and save some more. Other than that, I can only hope and pray that things will be better for her than they are for today’s generation of aspiring students.

College savings: What we’re doing so far

I’m glad I realized how important this issue would be to me so early in my daughter’s lives. The truth is, I’ve been socking money away for them since they were babies. It all started with money they received from relatives when they were born, or “free money” as I saw it.

Money that was likely meant for diapers and formula always made its way into my children’s savings accounts so fast their little heads would spin if they knew it. Then, once my second daughter was born, I started a 529 account in each of their names. And that’s when the savings really started to grow.

Since then, we’ve socked away any money they’ve gotten for birthdays and holidays, and contributed small amounts monthly ourselves. It all adds up.

In fact, it really is amazing how small amounts of money can grow over the months and years of a child’s lifetime. It’s hard to believe it, but my children already have thousands of dollars saved for college at the young age of 3 and 5. Still, I’m afraid it won’t be enough. That’s why, a couple of years ago, we started looking for other ways to grow the amount of money we would have available to pay for their college. And we didn’t need to look far.

Using rental income for college tuition

My husband and I became unlikely landlords in 2007 at only 27 years old. Our first rental was a small brick ranch home we chose to buy on somewhat of a whim. Shortly after its purchase, we turned our first home into a rental and upgraded into a slightly larger, nicer home for ourselves.

We weren’t sure what we were doing all the time, but we’ve always been happy to learn as we go and fly by the seat of our pants. And mostly through trial and error, we have learned a lot since then — so much that I’ve come to see our inexperience as a good thing. In a lot of ways, we were just too dumb to be afraid, which is probably the only reason we became landlords in the first place. In a strange twist of fate, it appears that our lack of awareness might have led to our best financial decision so far.

Regardless, we were making plenty of progress on the home’s respective 30-year mortgages by late 2011, but we still had many years left to go. But it was around that time that home mortgage rates began hitting record-lows and, as always, my wheels started turning.

I wondered if it would be possible to refinance our loans into loans with shorter, more-favorable terms. If we could, we might be able to move the process along and free up thousands of dollars of monthly income in the process. Even if we couldn’t refinance for some reason, I thought it was worth a shot.

Persistence pays off

Anyone who has ever refinanced a home knows what a huge pain the process can be. Well, trust me when I say that refinancing a rental home is an even more difficult experience then refinancing your primary residence. With both homes, the ordeal was somewhat of a nightmare.

Fortunately, after several months of trying and plenty of heartache, I was able to get both of our rental homes moved onto 15-year-loans. And amazingly, with a substantially lower interest rate, the monthly payments hardly budged. That means that our current rentals, while temporarily less profitable, will now be paid off in approximately twelve years — just in time for our daughter to turn 17. They currently rent for a little less than $2,000, but should rent for quite a bit more by then. And, if all goes as planned, most of that money will go straight into the college funds of my little girls.

Sometimes all we can do is save

The fact that the cost of a college degree has risen over 500 percent since I was my daughter’s age does not bring me comfort; but again, I can only control so much. I can’t change the fate of higher education any more than I can sit in my daughter’s school today and hold her hand.

I’m sure we’re all afraid of what kind of world our children might find when they graduate from high school. And if not, we probably should be. But we all know deep down that there is nothing we can do to soften this world for them. So we do what we can, and sometimes it means that all we can do is save for them and hope for the best.

On my daughter’s first ever day of school, I want her to know that I am proud of who she is and excited to see who she will become. And I want her to know that I’ll never stop worrying about her future, even if she asks.

I’m her mother, after all, and it just isn’t possible.

Are you worried about paying for college? Do you have any unconventional ways to pay for college?

This is a guest post from Kathleen O’Malley, who writes about finding joy in a simple, frugal life at Frugal Portland.

It happened fast. We barely talked about it, but all of a sudden, about a week after we got engaged — and before we were really ready — my fiancé and I had combined our finances.

I can pinpoint the impetus: Southwest Airlines was offering a promotion where if you got both the Plus and the Premier credit card and spent x dollars on one, y dollars on the other, you got a Companion Pass through the end of 2015. “We fly Southwest a lot anyway,” we reasoned. “And we’ll hit the minimums soon since this wedding we’re planning isn’t going to be cheap. We might as well get one of us a $5 ticket every time we fly somewhere together.”

So we applied for credit cards in both our names and started spending money on wedding-related things. The photographer wanted a deposit, but would she take payment in full seven months before the event? Of course she would! So too would the portable bathroom people and the half dozen other vendors required to turn a party into a wedding. Just like that, we’d hit those spending goals.

Combining checking accounts was easier than I expected. I prepared a full speech about how we should use my credit union instead of his “evil” bank, but my fiancé didn’t need a speech. He simply moved most of his money into my account, we put his name on it, and it was smooth sailing.

Until I went shopping with my sister a few weeks later.

I hadn’t purchased makeup in at least a year, and I was running low on supplies. We were at Sephora, and I had a few items in my little shopping basket. I calculated the cost: It was over $100. I started to panic. Blood rushed to my cheeks, my palms started sweating, and I could feel the tears welling up in my eyes. I couldn’t spend “his” money on makeup. That would be irresponsible!

See, up to this point, every time we swiped those cards, we were buying things together. Wedding stuff? Groceries? Dog food? Clearly distinguishable as combined spending. But this? This was something just for me.

Now, it wasn’t a frivolous purchase (or at least, not entirely), and it was absolutely something I would have bought without a second thought before we had joined financial forces. And the reason combining finances was smooth sailing from the beginning is because he knew my money philosophy inside and out, because he read Frugal Portland from start to finish, reading about my path into — and eventually out of — debt.

So I texted him. “I’m at Sephora with my sister. I want to buy makeup, but I’m feeling guilty.”

Immediately he texted back. “You don’t need my permission to buy makeup any more than I need your permission to buy a pizza tonight.”

I started to relax, then he wrote again. “We’ll run into issues like this and talk through them. We’re doing it together. I love you.”

I took a deep breath, squared my shoulders, and bought the makeup. My sister noted that I looked completely different after the text: more relaxed, more confident, happier. And I was.

That was a few months ago, and we’ve had our share of hiccups since then, but I’m glad we already have combined finances. I no longer see it as my money or his money. It’s our money. We have shared money goals — like saving half our income — and we’re on the same page. Saving half is something we do at the beginning of the month, and we keep the rest in our checking account. We still have the same credit cards, so there are no secrets.

It’s funny, actually. That one conversation — where I was so upset, worried, and nervous — was the only time either one of us asked for permission to spend. My sister and I were shopping online for her bridesmaid dress (would you believe it, the dog ate her original one?) and I asked if he had the credit card number memorized. He did, and rattled it back to me. “What did I just agree to?” he asked jokingly, after the transaction was complete.

The moral of this story is to pick a mate who shares your vision for financial goals. They don’t have to align 100 percent, but you ought to be able to talk openly about money with the person you’re spending the rest of your life with.

And try to save half your income.

This article is by staff writer Lisa Aberle.

When I wrote an article about poverty, I wasn’t sure where Brandon and Leah, the two people I shared about, would be in the next few months. I needn’t have wondered. Turns out, nothing has changed. Despite receiving money from various people for rent, access to free babysitting, and bags of groceries, the last few months have been peppered with evictions, arrests, jail, and now prison. Unfortunately, I am not surprised, and you probably aren’t either.

It is really easy for me to identify their stupid financial (and life!) decisions and ignore the impact that their life history has had on their future. But people don’t have to have drug addicts for parents or live in poverty to struggle financially or to struggle to fulfill life’s potential.

Take another friend I was talking to the other day. Barely into his thirties, Adam has a lot of things going for him: He’s healthy, has no consumer debt, and a job with lots of autonomy and flexibility, even if it’s not the highest paying job around.

“I feel like a failure,” he said, eyes lowered to the ground. “I’ll never be anything more than a manual laborer.”

“What do you mean?” I said, probably with more bluntness than the situation called for. “You’re in your thirties. Statistically, you have decades of working life ahead of you. If you don’t like what you’re doing, do something else.”

Slowly, he said, “It’s not that easy; I don’t know what to do. I am not good at anything.”

Talking with him is frustrating. Instead of offering solutions, I should just be quiet and listen — because I really don’t get it. My lifetime will not be long enough to complete all my dreams and schemes. And why can’t he see that he has potential to be just about anything else he wants to be? Not that there is anything wrong with manual labor at all, but apparently he’s not satisfied. Argh.

I don’t know all the factors that make us who we are, but the GRS editor sent me a link to an article that just might help people. Little people. Specifically, help little people become big people who tell the truth about themselves and about their future.

While you should go read this article to get the whole story, I’ll share a little. The author’s son’s teacher believes that her impact extends beyond teaching her students about math. Because of this, she asks her students to request four fellow classmates they would like to sit with the following week. The students know their written requests may or may not be honored.

Nice, right? But so what? What the teacher does with this information is the beauty of the story.

The author, Glennon Doyle Melton, writes: “Chase’s teacher is looking for lonely children. She’s looking for children who are struggling to connect to other children. She’s identifying the little ones who are falling through the cracks of the class’s social life. She is discovering whose gifts are going unnoticed by their peers. And she’s pinning down — right away — who’s being bullied and who is doing the bullying.”

The teacher is looking for children who are disconnected. They connect disconnectedness to school violence in the article, but that’s not the only thing that — in my opinion — is related to disconnectedness.

When she finds children who are disconnected, they just need a little help.

“It is like mining for gold — the gold being those little ones who need a little help — who need adults to step in and TEACH them how to make friends, how to ask others to play, how to join a group, or how to share their gifts with others.”

It makes me wonder about Brandon, Leah, and Adam. How would their life trajectories be different if someone had really paid attention to them when they were children? What if someone had poured truth into their souls, so that these three could tell themselves the truth about their past, present, and future selves? Because the lies we tell ourselves have a lasting impact, not to mention a potentially crushing impact on our financial health.

What if someone had been able to get Brandon to believe that his father’s abandonment had nothing to do with him? What if someone had been able to get Leah to understand that she was priceless … and she could wait for a guy who valued her accordingly instead of settling for addicts and abusers? What if someone had taught Adam how to share his gifts with others and not be ashamed if those gifts weren’t prized by society?

Who can deny that these situations have created people who make terrible (or, in the case of Adam, suboptimal) financial decisions? And in the case of Leah, in particular, her decisions have a ripple effect far beyond her personally. Taxpayers are funding her current and former stays in state prisons. Let’s not forget her children in the foster care system or her use of the legal system.

My optimistic heart holds onto the hope that it’s not too late for these adults to turn their lives around — but it’s easier to develop good habits in kids, right?

Speaking of easier, it would have been easier to write about saving money on baby stuff. Because writing this article has left me a little uncomfortable. But if I want to improve life for someone, I might need to get uncomfortable.

I’m uncomfortable because doing what this teacher does requires a commitment, a lasting commitment. It’s more than throwing money at a problem, it’s taking the time to get to know a child. It’s taking the time to mentor that child. And it requires patience to keep helping the child back up after he or she has failed. Clearly this is a marathon, not a sprint.

What do you think about this teacher’s approach? Have you ever done anything like this?

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