Does Health Insurance Cover Infertility Treatment?

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Victor Torres/Stocksy United

For most couples who are trying to conceive, health insurance is an essential part of the big picture. Paying for prenatal care and delivery without health insurance is a daunting proposition, and one that would become impossible for most couples if the pregnancy involved complications.

Fortunately, all new health insurance plans cover maternity care. That's a result of both the Affordable Care Act (ACA) and the Pregnancy Discrimination Act of 1978.

There are still some individual and small group grandfathered and grandmothered plans that don't cover maternity care, but they're steadily being replaced with ACA-compliant coverage.

Maternity and newborn care is one of the essential health benefit categories specifically addressed in the ACA. All new individual and small group plans must cover maternity and large group plans have been required to cover maternity for nearly four decades as a result of the 1978 law. So as long as you're covered under a group plan with at least 15 members, or any ACA-compliant plan in the individual or small group market, you've got coverage for the care you'll need once you're pregnant.

If Getting Pregnant Proves to Be an Obstacle

The U.S. Centers for Disease Control and Prevention (CDC) reports that about six percent of married women of child-bearing age are unable to conceive—due to both male and female infertility—and that 12 percent of women are unable to either get pregnant or carry a pregnancy to term.

So if you've received a diagnosis of infertility, you're certainly not alone.

But when you consider how expensive treatment can be, the financial aspects of infertility can become an obstacle for many couples. And while maternity care is included on all new health insurance plans in the U.S., there's no federal mandate requiring coverage for infertility.

Health Insurance and Infertility

Since 2014, the ACA's essential health benefits apply to all new individual and small group health plans. They don't apply to large group plans, though, but large group coverage is already fairly comprehensive and generous and many large employers self-insure, meaning that they can create the health insurance coverage that best helps them attract and retain high-quality employees.

Some aspects of health insurance coverage—like maternity care and preventive care, including contraceptive coverage—are mandated under federal requirements regardless of whether the health plan is purchased in the individual market or provided by an employer.

But coverage for fertility treatment is still relatively uncommon. It depends largely on state regulations, although employers can opt to offer fertility coverage even in states where doing so is not required.

Although the ACA includes 10 basic categories of essential health benefits, there's still considerable flexibility for states to define exactly how the essential health benefits would work.

Within parameters laid out by the ACA, each state picked its own "benchmark plan" to serve as a model for minimum health insurance coverage within the state in the individual and small group markets. Large group plans have more flexibility to define their own coverage.

For 2014-2016, benchmark plans were based on a plan that was sold in the state in 2012, so plans had to be altered in some cases in order to set the benchmark, as plans sold in 2012 did not yet have to be compliant with most of the ACA's provisions. For 2017 and beyond, the benchmark plan will be a plan that was sold in 2014, and therefore already fully-compliant with the ACA.

For the initial round of benchmark plan selections, there were 19 states that included some type of infertility testing or treatment, so all individual and small group plans in those states had to include at least those same benefits.

State Benchmark Plan Variations

The 19 states include: Alabama, Arkansas, Connecticut, Georgia, Hawaii, Iowa, Illinois, Kansas, Massachusetts, Maryland, Montana, North Carolina, New Jersey, New Mexico, Nevada, New York, Rhode Island, South Dakota, and Wyoming.

But across those 19 states, the coverage requirements for infertility vary greatly. In Kansas, for example, the "diagnosis and treatment of cause of infertility" is covered, but in vitro fertilization (IVF) or "any other medically-aided insemination procedure" is excluded from the benchmark plan's coverage, meaning that it can also be excluded from coverage on other plans in the state.

In Wyoming, the benchmark plan includes coverage for infertility testing and treatment but excludes "extraordinary procedures to induce fertilization with technical assistance to include surrogate motherhood, gamete intrafallopian transfer, invitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer, artificial insemination, gestational carrier, and preimplantation genetic diagnosis testing."

The exclusion for "extraordinary procedures" includes IVF and artificial insemination. These are probably measures that people going through infertility treatment wouldn't consider extraordinary, but the exclusion in the benchmark plan means that other plans in the state can exclude them as well.

North Carolina's benchmark plan includes up to $5,000 in coverage to diagnose the cause of infertility, correct underlying causes of infertility, and if necessary, provide for artificial insemination. But the coverage does not extend to IVF, gamete intrafallopian transfer (GIFT), or zygote intrafallopian transfer (ZIFT).

Maryland's benchmark plan also excludes IVF, GIFT, and ZIFT.

A full list of the benchmark plan summaries for each state is available here. The benefits included in each state's benchmark plan are required to be included in all individual and small group plans sold in that state. But they neither apply in the large group market nor coverage that isn't regulated by the ACA, including short-term plans and Health Care Sharing Ministries

State Mandates

There are 15 states that have mandates—separate from the ACA and its essential health benefits/benchmark plan requirements—requiring at least some coverage for infertility testing and/or treatment. They include Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. 

But just as with the benchmark plan requirements, there are a lot of caveats in the state mandates. Many of them only apply to employer-sponsored plans with at least 25 or 50 employees and some of them exclude IVF, ZIFT, and GIFT.

New Jersey's coverage mandate is robust, but it only applies to employers with at least 50 employees. And although Arkansas includes both individual and group plans in their mandate (which does require coverage for IVF), they exclude HMOs and self-insured plans. Indeed, self-insured plans are exempt from the fertility coverage mandate in all 15 states where a mandate exists. 

For people buying coverage in the individual market, there are a few states where coverage for infertility treatment is included and includes procedures like IVF. They include Arkansas, Connecticut, Hawaii (one IVF procedure per lifetime), Illinois, Massachusetts, and Rhode Island. 

Questions to Ask

If you know or suspect that you might need infertility treatment, the right health insurance plan can help dispel at least some of the financial worries that go along with infertility. Here are some questions to ask before you enroll in a health plan:

  • Are you in a state that has some level of mandated coverage for fertility treatment? If so, make sure you understand how the mandate applies—is it only in the group market or does it apply to all fully-insured plans including those sold in the individual market?
  • If you've got an option to enroll in a plan through your employer, find out if the plan is self-insured or fully-insured. Self-insured means that the employer pays for medical costs directly, although they may contract with a third party to manage the plan. Fully-insured means that the health plan is maintained by an insurance carrier and the employer purchases coverage from the insurance company. If it's fully-insured, it has to follow both state and federal regulations. If it's self-insured, federal regulations apply. And while there are no federal mandates for infertility treatment, you may find that your employer's self-insured plan does include some coverage for infertility treatment.
  • If your employer offers more than one plan, read the fine print on all of them. One might include infertility treatment while another might not. 
  • Even if you're not in a state with a mandate for infertility treatment, you may be employed by a business domiciled in a state with a mandate. In that case, you may find that the health insurance offered by your employer covers infertility treatment regardless of where you live.
  • If you buy your own health insurance, understand the benchmark plan requirements in your state. Your state's Department of Insurance will be able to answer any questions you have about state mandates and/or the benchmark plan.
  • If you're in a state that has a mandate and/or benchmark plan inclusion for coverage of fertility treatment in the individual market, you might want to consider purchasing an individual plan even if you have an option to get coverage through a self-insured employer-sponsored plan. Obviously, you'll have to crunch all the numbers to see if it makes sense overall and almost certainly have to pay full-price for the individual plan (no premium subsidies) since you have access to an employer-sponsored plan. But since the mandates and benchmark plan requirements don't apply to self-insured employer-sponsored plans, you might end up coming out ahead with an individual market plan in the handful of states where individual plans provide robust coverage for treatment like IVF.

 

Sources:

Centers for Disease Control and Prevention, Infertility FAQs http://www.cdc.gov/reproductivehealth/Infertility/index.htm

CMS, Center for Consumer Information and Insurance Oversight, Information on Essential Health Benefits (EHB) Benchmark Plans https://www.cms.gov/cciio/resources/data-resources/ehb.html

Robert Wood Johnson Foundation, Essential Health Benefits; 50-State Variations on a Theme, October 2014 http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf416179

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