Orlando Harmon
Fertility treatments can be expensive, and often insurance companies do not cover them. In the US, whether or not insurance covers fertility treatments depends on the state in which the person lives, and the size of their employer. Some states require insurers to cover the diagnosis of infertility, and some require coverage of treatment, including IVF. However, this does not apply to self-funded plans, which cover 61% of workers with employer-sponsored health insurance.
| Characteristics | Values |
|---|---|
| Short-term medical insurance | Temporary health insurance or term health insurance |
| Coverage | Not considered "minimum essential coverage" as defined in the Affordable Care Act; may not cover all essential health benefits in your state |
| Application | Short application questions; may take effect the day after your application is received |
| Cost | May be cheaper than ACA plans |
| Coverage of fertility services | Varies by state; some states require coverage of fertility services for some fully-insured private plans |
| Fertility treatments | Not typically covered by private insurance plans or Medicaid programs; some insurance plans cover IVF but not accompanying injections |
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What You'll Learn
Short-term insurance plans are not Minimum Essential Coverage
MEC plans, on the other hand, are qualified health plans that meet the minimum essential health coverage required by the ACA. These plans must cover pre-existing conditions, follow limits related to cost-sharing, and prohibit lifetime and annual benefit limits. They also need to provide 10 essential health benefits, such as emergency services, hospitalization, maternity and newborn care, mental health services, prescription drugs, and rehabilitative services.
The purpose of MEC is to ensure that individuals have access to plans with good benefits and adequate health protection. Without MEC, individuals may face inferior health protection and miss out on valuable benefits. Additionally, in the past, individuals who lacked MEC were subject to financial penalties. Although the Tax Cuts and Jobs Act of 2017 removed this penalty, some states, such as California, Massachusetts, New Jersey, Rhode Island, and Washington, D.C., still penalize residents who lack health insurance coverage under individual mandate laws.
It is important to note that while short-term insurance plans are not MEC, there are other options for individuals seeking fertility coverage. Some private insurance plans cover diagnostic services, and a few states require coverage of fertility services for certain fully-insured private plans. Additionally, fertility preservation services may be covered when a medical treatment may directly or indirectly cause iatrogenic infertility, which is an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatments affecting reproductive organs or processes.
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Fertility treatments are often not covered by insurance
In the United States, insurance coverage of fertility services varies by state and, for people with employer-sponsored insurance, the size of their employer. Only a handful of states require coverage of fertility services for some fully-insured private plans, and these requirements do not apply to health plans that are administered and funded directly by employers (self-funded plans), which cover six in ten workers with employer-sponsored health insurance.
In New York, a bill was passed in 2019 to require IVF and fertility preservation services for comprehensive private health insurance policies. The New York State Department of Financial Services estimated that premiums would increase by 0.5% to 1.1% due to mandating IVF coverage, and 0.02% for mandating fertility preservation for iatrogenic infertility. Similarly, in California, a bill was proposed to require private plans and Medi-Cal managed care plans to cover IVF services, which was estimated to increase premiums by approximately $5 in the private market and less than $1 for Medi-Cal plans.
In certain situations, insurers must cover standard fertility preservation services when a medical treatment may directly or indirectly cause "iatrogenic infertility," which is an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. Standard fertility preservation services required to be covered include the collecting, freezing, preserving, and storing of ova or sperm, prescription drugs, and other standard services that are not experimental or investigatory.
In addition, large group insurers are required to provide coverage for the diagnosis and treatment of infertility and fertility services, including IVF. For small group fully-insured plans, insurers are required to offer coverage of infertility treatment, except IVF.
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Fertility treatments are expensive
In the United States, insurance coverage of fertility services varies by state and, for people with employer-sponsored insurance, the size of their employer. Many fertility treatments are not considered "medically necessary" by insurance companies, so they are not typically covered by private insurance plans or Medicaid programs. When coverage is available, certain types of fertility services (e.g., testing) are more likely to be covered than others (e.g., IVF). A handful of states, including Arkansas, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, and Rhode Island, have laws that require insurers to cover the diagnosis of infertility, treatment of infertility, and/or fertility preservation services.
In some cases, insurers must cover standard fertility preservation services when a medical treatment may directly or indirectly cause "iatrogenic infertility," which is an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. Standard fertility preservation services required to be covered include the collecting, freezing, preserving, and storing of ova or sperm, prescription drugs, and other standard services that are not experimental or investigational.
Large group comprehensive health insurance policies must also cover three cycles of in-vitro fertilization (IVF) used to treat infertility and prescription drugs that are prescribed for the IVF treatment. However, there may be a lifetime maximum for coverage, such as $15,000, and IVF procedures must be performed at a licensed or certified facility. Additionally, individuals may be required to pay cost-sharing, such as deductibles, copayments, and coinsurance, for infertility services, IVF, and fertility preservation services.
Short-term health insurance, also called temporary health insurance, can be a solution to fill gaps in coverage. These plans are medically underwritten and are not considered Minimum Essential Coverage as defined in the Affordable Care Act. They may not cover all Essential Health Benefits in your state and do not provide coverage for pre-existing conditions. Short-term plans can be a flexible and fast option for temporary health insurance coverage, but it is important to carefully review the policy for any exclusions or limitations.
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Fertility preservation services are covered by some insurers
In some cases, insurers are required to offer coverage for fertility preservation services when a medical treatment may directly or indirectly cause "iatrogenic infertility". This refers to when a person becomes infertile due to a medical procedure done to treat another problem, often chemotherapy or radiation for cancer. In these cases, standard fertility preservation services required to be covered include the collection, freezing, preservation, and storage of ova or sperm, prescription drugs, and other standard services that are not experimental or investigational.
In the US, a handful of states require coverage of fertility services for some fully-insured private plans, but these requirements do not apply to health plans that are administered and funded directly by employers (self-funded plans). For example, in 2019, New York passed a bill requiring IVF and fertility preservation services for comprehensive private health insurance policies. Similarly, Colorado recently enacted a requirement for individual and group health benefit plans to cover infertility diagnosis, treatment, and fertility preservation for iatrogenic infertility, effective January 2022.
In terms of specific insurance providers, HealthPartners offers advisors through FamilyPath who can answer fertility-related questions and guide individuals through the process. Additionally, HealthPartners provides coverage for mental health care related to fertility treatment, which is included in the $30,000 limit for the fertility treatment benefit.
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Fertility treatments are covered by some state insurance plans
Fertility treatments are costly and often not covered by insurance. However, some states have laws requiring certain health plans to cover at least some infertility treatments. These laws vary by state and the size of the employer. For example, in California and Texas, insurers offering group health plans must offer coverage for infertility treatments, but employers can decide whether to provide this benefit to their employees.
In some states, such as New York, laws have been passed to require IVF and fertility preservation services for comprehensive private health insurance policies. Other states, like Oklahoma, have laws that require health benefit plans to provide coverage for standard fertility preservation services for individuals diagnosed with cancer within reproductive age when medically necessary treatments may cause iatrogenic infertility.
Additionally, some states require coverage of fertility services for fully-insured private plans regulated by the state. However, these requirements do not apply to self-funded plans administered and funded directly by employers, which cover a significant proportion of workers with employer-sponsored health insurance.
It is important to note that even within a state, coverage can vary depending on the specific insurance plan and the individual's circumstances. For example, in Minnesota, the Minnesota Advantage Health Plan offers a fertility treatment benefit with a $30,000 lifetime cap, but prescription drug coverage is separate and has no dollar limit. This plan also includes a travel benefit to help pay for transportation and lodging if individuals need to travel more than 100 miles from home to receive fertility care.
Therefore, while some state insurance plans do cover fertility treatments, the extent of coverage varies widely, and it is essential to carefully review the specifics of any insurance plan when considering fertility treatments.
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Frequently asked questions
Short-term medical insurance is not "minimum essential coverage" as defined by the Affordable Care Act and may not cover all essential health benefits in your state. It is important to check your policy carefully to see if fertility treatments are covered.
Coverage varies depending on the state and the insurance provider. Some insurance plans cover in vitro fertilization (IVF) but not the accompanying injections that women may also require. Other plans cover both. Some plans cover limited attempts at certain treatments. And some plans do not cover IVF at all.
Out-of-pocket costs vary widely depending on the patient, state of residence, provider, and insurance plan. Diagnostic lab tests, semen analysis, and ultrasounds are generally less expensive than diagnostic procedures or surgery. Fertility medications are less expensive than IUI and IVF, but even the least costly treatments can still result in thousands of dollars in out-of-pocket costs.
