Health Insurance and Infertility Treatment Coverage
You're mostly out of luck if you get health coverage through the federal marketplace, Medicare, or Medicaid. If you get it through an employer, though, it may just help you pay for this often-pricey medical care.
Health insurance can cover a lot of kinds of medical care and treatments.
A lot of people probably think fertility drugs or infertility treatments are among the services your average health plan is less likely to cover. And in a way, they're right--most health plans don't pay for this type of care--or at least they don't pay for its most expensive components.
Still, it's far from impossible to find health insurance that covers infertility treatments. This is especially true if you get your coverage through an employer--the larger, the better.
Unfortunately, you'll have a tougher time if you rely on the federal and state marketplaces set up by the Affordable Care Act, or if you rely on Medicaid or Medicare.
Keep reading to learn more about how all of these forms of health insurance do and don't help enrollees financially deal with their fertility woes.
The Basics of Health Insurance and Infertility Treatment Coverage
The first thing you need to know here is the federal government doesn't require insurance companies to make this coverage available to Americans. It also doesn't require U.S. businesses to provide this coverage to employees.
Although the Affordable Care Act, also called the ACA or Obamacare, mandates that health insurance companies in the U.S. cover 10 categories of "essential" benefits--like inpatient and outpatient hospital care, prescription drug coverage, preventive services, and more--none of them include infertility treatments.
And because the federal government also doesn't require insurers to cover infertility treatments in any other way--such as through Medicare or Medicaid--a good number don't do it. (That said, 15 states do require their insurance companies to offer this kind of coverage in some form or fashion. For a full list of these states and the details of their mandates, read the "Frequently Asked Questions" section of this article.)
Despite the fact that they're rarely forced to do so, many insurance companies still cover infertility treatments to some extent. This is mostly true for group plans businesses provide to employees, but it's possible to find individual plans that include infertility coverage, too, if you shop around.
What Does 'Infertility Treatment' Mean?
Don't be fooled by the phrase, "some health plans cover infertility treatments."
The fact is, there's a wide range as to what constitutes infertility treatment coverage when it comes to health insurance.
Why? The main reason is a lot of procedures and services fit under the "infertility treatment" umbrella. A few examples:
- Diagnostic testing
- Fertility drugs
- Intrauterine insemination (IUI)
- In vitro fertilization (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Gamete intrafallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
For IUI, a concentrated amount of sperm is deposited directly into a woman's uterus around the time her ovaries release one or more eggs. With IVF, eggs are removed from the woman's ovaries and then combined with sperm. If the procedure is successful, the resulting embryo returns to the uterus.
ICSI, on the other hand, involves injecting sperm directly into eggs obtained through IVF. Both the GIFT and ZIFT treatments see sperm and eggs mixed in a lab and then deposited into the fallopian tubes via surgery.
As for other surgical procedures, they're often used to:
- open blocked fallopian tubes
- remove endometriosis tissue
- remove fibroids
- treat polycystic ovarian syndrome
All You Need to Know About Fertility Drugs
Given all of the above, is it any wonder health insurance plans differ wildly in how they do and don't cover infertility treatments?
Many provide no coverage at all, of course. Others cover just the diagnosis, or certain drugs. Still others cover the gamut--everything from diagnosis to drugs to procedures like IVF.
As such, it's important to read the fine print of any health plan that is offered to you or that makes your short list (if you're buying insurance on your own, without the assistance of an employer).
That's where you'll find out exactly what a particular plan covers or doesn't cover. It's also where you'll find out if there are any exclusions or limitations that might keep a plan from covering your infertility procedures or services in a timely manner--or at all.
After all, not all insurance companies define "infertility" or "infertility treatment" in the same way. Some require people seeking this kind of coverage to be infertile due to a medical problem. Some require them to make a certain number of attempts to get pregnant naturally, or to attempt it for a certain period of time, before extending coverage. Some require these failed attempts to be tied to through sexual intercourse--which usually makes single and gay women ineligible.
If a health insurance policy you're considering doesn't make any of the above clear to you, talk to someone in human resources (if you get health insurance through your job) or contact someone at your insurer.
Not sure what to ask that person? Here are a few suggestions for both situations.
Questions to Ask Your Health Insurance Company About Infertility Treatment Coverage
It isn't always easy to tell if a health insurance policy covers infertility treatments by reading the fine print. To be absolutely clear one way or the other, you've got to talk with someone at the insurer.
When you do that, be sure to ask them the following questions:
- Does my plan cover infertility treatments? If so, which ones?
- Are there any restrictions related to this coverage? For example, does my plan restrict or limit coverage based on age?
- Do I have to try certain drugs or treatments before moving on to others?
- Do I have to undergo specific tests before my plan covers any further treatments?
- Do you need to pre-authorize any procedures my physician recommends?
- Do I need to get referrals for the specialists who will perform these procedures?
- Does my plan cover fertility medications?
- Are there any restrictions or limitations related to this coverage?
- What are my options if I decide to seek advice or treatment outside my plan's network?
- Who do I contact if I have questions or if I run into any problems?
Talk with Your Employer, Too
If you get health insurance through an employer, don't leave its HR department out of this conversation.
Some people are more comfortable talking with a colleague about this topic than they are talking with a stranger over the phone. So, start with your HR contact if you think it will ease you into things.
When you do that, ask them the questions listed above. You may want to ask a few others, too.
For example, if your current plan doesn't cover infertility treatments, ask if your employer offers any other plans that do cover them. Also ask:
- What is the difference in cost between my current plan and these others?
- How and when can I change plans?
- Will you continue to offer this plan or coverage next year?
If your employer doesn't offer a health plan that covers the kinds of infertility treatments you need, don't give up. At least one survey suggests a main reason companies and organizations decide to provide these benefits is their employees asked them to do so.
So, if you want your health insurance to pay for infertility drugs or treatments, don't be afraid to ask for it.
Frequently Asked Questions
Q: How many women or couples are infertile?
A: According to the Centers for Disease Control and Prevention (CDC), just over six million women between the ages of 15 and 44 in the United States have difficulty getting pregnant or staying pregnant. That means around 10 percent of U.S. women are infertile at any point in time.
Q: How many women or couples have sought help for fertility problems?
Just over 7.3 million U.S. women between the ages of 15 and 44 have ever used "infertility services," reports the CDC. In other words, about 12 percent have sought help for fertility issues at some point in their lives.
Q: Does Obamacare require health insurance plans to cover infertility treatments?
A: No, it doesn't. Although Obamacare requires health insurance companies to cover 10 categories of services known as "essential health benefits," infertility treatment is not one of them.
What that means is, if your health plan didn't cover fertility treatments before the ACA became law in 2010, it doesn't have to cover them now.
This doesn't mean no plans do anyway, though. In fact, according to The New York Times, nearly two-thirds of companies with more than 500 employees have health plans that pay for an initial evaluation by a fertility specialist. Just under half of these large employers cover infertility drug therapies. About a third cover IVF.
Of course, this means a lot of employers don't offer health plans that cover infertility treatments. And that's not always the fault of the insurance companies backing their plans. In many cases, insurers offer the coverage, but employers decide not to include it in their health packages.
Q: Which states require insurance companies to cover infertility treatments?
A: Even though the ACA doesn't require health insurers to cover this kind of care, a number of states require it anyway--to a point.
Specifically, these 15 states currently require insurance companies to offer coverage for infertility treatment:
- New Jersey
- New York
- Rhode Island
- West Virginia
What they require of insurers differs from state to state. Some require infertility medication coverage. Some require IVF coverage. Some place lifetime maximums or other limits on coverage. Some only require large group plans to offer this coverage.
Something to keep in mind here even if you live in one of the states included on this list: these mandates usually only apply to state-regulated plans. That often means the ones provided by large employers are exempt. (Because most large employers are self-insured.)
Actually, all self-insured plans are exempt, so some plans offered by small employers may not provide this kind of coverage even if they're located in one of the 15 states mentioned above.
Don't assume you're set if you live in one of these 15 states and your employer isn't self-insured. There are still other aspects to these mandates that could keep you from obtaining this coverage. For example, some state laws limit where someone can have a procedure done if it's going to be covered. Others restrict who can receive it by requiring couples to attempt to get pregnant through sexual intercourse. And some require treatments to use a spouse's sperm. (These last two stipulations make it difficult, if not impossible, for single or gay women to get this coverage.)
All of which reinforces how important it is to do your research and ask plenty of questions if your goal is to have some type of infertility treatment covered by your health plan.
To learn more about how your state does or doesn't require this kind of coverage, go to resolve.org.
Q: How many U.S. employers offer health plans that cover infertility treatments?
A: According to one 2013 study, 65 percent of businesses with more than 500 employees offer health insurance plans that cover the cost of an initial fertility evaluation. The same study found just over 40 percent of large employers cover fertility drugs or drug therapies, while about 27 percent cover IVF treatments.
Q: Does Medicaid cover infertility treatments?
A: The federal government doesn't require state Medicaid programs, which provide basic support to low-income families, to cover fertility testing or infertility treatments. As a result, none of them pay for this sort of care.
Still, some Medicaid programs cover diagnostic services to detect the underlying medical reasons for infertility. To find out if that's true where you live, contact your local Medicaid agency.
Q: Does Medicare cover infertility treatments?
A: In short, no, it does not. Medicare doesn't cover infertility treatments--or at least it doesn't cover the ones described and discussed here.
It shouldn't be a surprise to hear Medicare Part A doesn't cover this kind of medical treatment. Medicare Part A covers inpatient hospital stays, which infertility treatments don't require.
Medicare Part B, on the other hand, mostly covers "medically necessary" and preventive services. As such, it may pay for some medically necessary fertility treatments, but it's hard to say which ones. Don't expect Medicare Part B to cover any of the costs related to IVF treatments, though.
As for Medicare Part D, although these plans help people pay for prescription drugs (something neither Part A nor Part B cover), they don't help pay for those that are "used to promote fertility."
Q: Do Medicare Supplement or Medicare Advantage plans cover infertility treatments?
A: It's possible some Medicare Supplement (also called Medigap) or Medicare Advantage plans cover infertility treatments. Don't assume this, though. Read the fine print of any policy you're thinking of buying. If that doesn't make things clear, talk with someone at the insurance company.
For more information on these kinds of Medicare coverage, read our "Ultimate Guide to Medicare Advantage" or this article: "When Does it Makes Sense to Get a Medicare Supplement Plan?"
Q: How much does infertility treatment cost?
A: It depends on the kind of treatment. For instance, oral fertility drugs (like Clomid), which induce ovulation in women, cost between $5 and $20 per month, according to thebump.com. Combine them with IUI and ultrasound monitoring, and that figure could balloon to between $500 and $700 a month or as much as $3,000 a cycle--if you pay out of pocket.
Most other treatments are even more expensive. Injectable hormones (used with IUI) often cost $1,000 to $5,000 a month, says babycenter.com. Surgical interventions may cost as little as $2,000 or as much as $10,000. IVF and all of the medications and procedures that usually go along with it can set you back $12,000 or more per cycle. Add ICSI to that, and expect to pay about $1,400 to $2,000 more. And according to verywell.com, you could pay $25,000 to $30,000 if you have IVF with egg donation.
Q: How successful are infertility treatments?
A: Once again, it depends on the treatment. It also depends on the specific fertility problems you're experiencing. Your age plays a role, too.
Medications, surgery, and IVF have the highest success rates (of up to 40 percent or more), based on a number of sources. Whether or not any of those treatments or procedures are right for you, though, depends on your situation.
Focusing specifically on IVF, verywell.com describes it as being "generally successful"--for women who are younger than 35 and who use donor eggs, in particular. Even for women of all ages, though, it reports "the odds of a live birth are between 34 and 42 percent over three [IVF] cycles."
That said, IVF success rates drop substantially the older a woman gets, especially if she uses her own eggs.
Q: How can I save money on infertility treatments, especially if my insurance won't cover them?
A: If your health insurance won't cover your fertility drugs or treatments, the following could help you cut your out-of-pocket costs:
- Offer to pay in cash
- Shop around and research a number of clinics
- Try to negotiate a better price
- Use a health savings account or flexible spending account, if you have access to one
- Look for pharmaceutical discount programs (to save money on fertility drugs)
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