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It's (finally) getting easier to get insurance coverage for infertility

It's (finally) getting easier to get insurance coverage for infertility

Nicole Knight, AHCJ | April 22, 2020 | Getting Pregnant

To mark National Infertility Awareness Week, we’re discussing assisted reproductive technologies and have mapped out a game plan for you to find out if your state requires infertility coverage or if your employer provides it. 

We’ll also describe strategies to help you discover which services are covered, and arm you with questions to ask your insurance provider or benefits manager. And we tell you where you  may find financial assistance for infertility treatment to make it more affordable.

Assisted reproductive technology is an avenue for many people to become parents. It’s also astonishingly, and often prohibitively, expensive — especially in vitro fertilization (IVF). The average IVF cycle costs $12,400, not including fertility drugs, specialized testing, or storage fees for eggs and embryos (1). 

The cost burden of infertility treatment creates a patchwork of haves and have-nots in this country. Unsurprisingly, people in states where insurance must, by law, provide infertility coverage use the services at higher rates than individuals living where there’s no such legal mandate (1).

The good news?

More states now require insurance coverage of infertility services. In April, Colorado became the 18th state to enact this type of family-friendly legislation. The law goes into effect in 2022 (2, 3).

Nationally, a bill introduced in Congress — the Access to Infertility Treatment and Care Act — would require healthcare plans to cover infertility treatments and fertility preservation services (4). 

Outside the halls of government, employers are also waking up to the advantages of infertility benefits as a tool to attract and retain workers. Nearly one-third of companies with 500+ employees offer an infertility benefit these days. That’s up from 24% in 2016, according to research from the International Foundation of Employee Benefit Plans (5). 

The study found that the most commonly covered services were (5):

fertility-coverage-insurance

This is all welcome news, particularly if your state requires insurance coverage, or your employer offers the benefit. Still, infertility benefits aren’t always easy to understand or use — even when you have them.

Does my state require insurance coverage of infertility services?

The National Infertility Association provides a helpful directory of the states that presently require infertility coverage (3). (Infertility and fertility are defined differently when it comes to insurance, which we’ll get to.) 

If you live in one of these states, do some digging. You’ll want to find out whether the law applies to your employer and to your type of insurance. 

Some states carve out exceptions for small employers, such as those with 50 employees or less. These employers don’t have to provide insurance coverage of IVF and other infertility treatments unless they want to voluntarily (3).

Some state laws only apply to certain categories of health plans. For example, fully insured plans must follow state law — meaning they must offer infertility coverage if there’s a state mandate. Self-insured plans are generally exempt, and so are plans from religious employers (3). 

Some states impose a waiting period before you can use insurance coverage. Connecticut law, for example, requires you to carry your insurance plan for a year before you can use an infertility benefit (3).

Grappling with the ins and outs of insurance can be a headache. But grasping the details of what’s provided — and what’s not — might save you thousands of dollars on infertility treatment. 

Beyond what state law may, or may not dictate, keep in mind that your employer may offer infertility benefits even if state law doesn’t require it. 

Is there a difference between fertility and infertility coverage?

In general, your doctor must diagnose you or your partner with infertility to qualify for state-mandated insurance coverage. This means that blood tests, lab work, fertility drugs, and so on are an out-of-pocket expense until an infertility diagnosis (3). So, for example, if you were curious about your egg reserve or another marker of your fertility, but have’t been officially diagnosed as infertile, your insurance likely wouldn’t pay for it.

What is infertility? States don’t necessarily follow a one-size-fits-all definition. For example, here’s how California insurance law defines infertility (3):

“Infertility means the presence of a demonstrated condition recognized by a physician and surgeon as a cause of infertility or the inability to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.”

And here’s Massachusetts (3):

“Infertility means the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1-year or 6-month period.”

You can find out how your state defines infertility on The National Infertility Association site (3).

Your next step is finding out the infertility services covered in your state insurance law. 

Which infertility services does my insurance cover?

State-mandated coverage requirements run the gamut. Some states require insurance plans to pay for a set number of IUI or IVF cycles. Others place a spending cap on infertility services. For example, Rhode Island imposes a $100,000 lifetime cap on treatment expenses. In Arkansas, it’s $15,000 (3). 

Other states leave it up to insurance companies to decide whether to cap services or not (3). 

However, your employer, if they provide infertility benefits, may decide to provide more generous benefits than what the law requires. You’ll want to find out what’s available to you.

Call your insurance provider to learn what’s covered and what isn’t. Some questions to ask may include (3):

  • Are there age limits?
  • Do I need to be married?
  • Are there yearly or lifetime caps on coverage?
  • What does coverage look like for same-sex partners?
  • Do I have to try intrauterine insemination (IUI) before IVF is covered?

You may also  be able to look up the information yourself in your online account with your insurance provider; look for your plan’s Summary of Benefits and Coverage (SBC) (6). Here’s an example of one

If your current plan doesn’t cover infertility, consider talking to your workplace benefits manager about switching to a plan with infertility benefits or advocate for the benefit if it’s not offered in any workplace plans. 

More and more employers are taking infertility coverage seriously. They realize employees may turn down a job offer or leave a company that doesn’t provide the benefit. Nearly two-thirds of millenials in a national survey said they’d be willing to switch jobs to ensure they had infertility coverage (7). 

What if my insurance coverage isn’t enough?

Unfortunately, out-of-pocket costs even with insurance coverage are difficult to avoid. You can expect co-pays and may need to reach your deductible before your infertility benefits kick in. Review your Summary of Benefits and Coverage for more information. 

To stretch your dollar, use a health savings account (HSA). An HSA allows you to save pre-tax dollars for medical costs that aren’t covered by insurance. Federal law allows you to use HSA money for “fertility enhancement” services, which includes IVF, egg freezing, and fertility-related surgery (8).

If you have a flexible spending account (FSA), check with your FSA administrator to see if you can use the funds to reimburse yourself for costs associated with infertility treatments.

Also, take advantage of grants and scholarships to help you pay for treatment. You can find a list of foundations offering financial assistance on The National Infertility Association’s website (9).

Your infertility journey needn’t break the bank if you arm yourself with knowledge — and take advantage of all of the resources at your disposal.



References:

  1. Insogna, I., & Ginsburg, E. (2018, December). Infertility, inequality, and how lack of insurance coverage compromises reproductive autonomy. AMA Journal of Ethics, 20(12), E1152-1159.
  2. Colorado state legislature. (2020, April). HB20-1158
  3. The National Infertility Association. (n.d.). Infertility coverage by state.
  4. Sen. Cory Booker. (2019, May). Booker, Menendez, DeLauro introduce bill to increase access to infertility treatment.
  5. Mayer, Kathryn. (2019). 6 most commonly covered fertility benefits. Employee Benefit News.
  6. Centers for Medicare & Medicaid Services. (n.d.). Sample summary of benefits and coverage.
  7. Reproductive Medicine Associates of New Jersey. (2015). Infertility in America.
  8. Internal Revenue Service. (2019). Publication 502, Medical and Dental Expenses.
  9. The National Infertility Association. (n.d.). Infertility treatment grants and scholarships.