Jeffrey Wade
The cost of fertility treatments can be very expensive for those who lack coverage, and many patients lack access to fertility services due to their high cost and limited coverage by private insurance and Medicaid. While some insurance companies may cover fertility treatments, many do not consider them medically necessary. In the US, insurance coverage varies by state, and while some states require coverage of fertility services for some fully-insured private plans, these requirements do not apply to self-funded plans administered and funded by employers. In 2019, New York passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies, and other states have followed suit. Ultimately, it is the patient's responsibility to obtain the required referral and authorization prior to their appointment, and to understand their insurance coverage.
| Characteristics | Values |
|---|---|
| IVF coverage | Coverage depends on the insurance provider, state, and individual circumstances. |
| IVF cost | The cost of one standard IVF cycle was approximately $12,500 in 2009 and is likely higher today. |
| Out-of-pocket costs | Out-of-pocket costs for IVF vary depending on the patient, state of residence, provider, and insurance plan. |
| Insurance providers | Some insurance providers, such as Aetna, offer IVF coverage for eligible plans. |
| Pre-authorization | Some insurance plans require pre-authorization and a referral before covering IVF treatments. |
| Number of cycles | The number of IVF cycles covered varies by insurance plan. |
| Religious organizations | Religious organizations are not required to provide IVF coverage. |
| Self-insured employers | Self-insured employers are generally exempt from providing IVF coverage. |
| Large group coverage | Insurers that cover IVF procedures for large groups may require trying basic infertility treatments first. |
| Storage costs | Insurers must cover embryo storage until the third IVF cycle for large group coverage. |
| Formulary requirements | Prescription drugs for IVF may be subject to the insurer's formulary requirements, but they must have a process for requesting off-formulary drugs. |
| In-network providers | Insurance coverage for IVF may be limited to in-network providers. |
| Surrogacy | Health insurance policies typically do not cover IVF treatments for surrogates who are not covered under the policy. |
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What You'll Learn
IVF coverage depends on state and insurance type
In the United States, insurance coverage for IVF treatments often determines whether people requiring fertility treatment can afford to grow their families. While federal law does not require any health plans to cover infertility treatments, some states have passed fertility insurance coverage laws that include IVF. As such, insurance coverage for IVF varies significantly depending on the state and type of insurance.
As of September 2023, 21 states and the District of Columbia have passed fertility insurance coverage laws, with only 15 of those laws including IVF coverage. However, these state laws often do not apply to self-insured plans, which cover 61% of workers in the U.S. Additionally, employers with fewer than 50 employees are generally exempt from the requirements of the law. Therefore, even in states with IVF coverage mandates, employers may not be required to cover infertility treatment if they are self-insured or have a small number of employees.
The cost of IVF treatments can be significant, ranging from $14,000 to $30,000 per cycle, and it often takes multiple cycles to achieve a successful pregnancy. As a result, insurance coverage can play a crucial role in making IVF more accessible and affordable for individuals and couples seeking to grow their families.
The specific rules and requirements for IVF coverage vary by state and insurance provider. For example, in Connecticut, all insurers are required to provide coverage for IVF and other infertility treatments for those who have been unable to get pregnant for one year if under 35 or for six months if over 35. On the other hand, states like California only require insurers to offer diagnostic and treatment options to employers, who then decide whether to adopt the benefits for their employees.
When determining IVF coverage, it is important to carefully review your insurance plan and understand the specific requirements and limitations. Some insurance plans may require pre-authorization or a referral from a doctor before covering IVF treatments. Additionally, there may be restrictions on the number of IVF cycles covered, with some plans offering up to three cycles per live birth. Understanding your insurance coverage and seeking guidance from a healthcare professional can help individuals and couples make informed decisions about their fertility treatment options.
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Some insurers cover IVF as fertility preservation
While the law does not require insurers to cover IVF or other assisted reproductive techniques, some insurers do cover IVF as fertility preservation. In 2019, New York passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies. Large group comprehensive health insurance policies must cover three cycles of IVF used to treat infertility and prescription drugs that are prescribed for the IVF treatment. Large group means a group of more than 100 employees.
In addition, individual, group, and blanket health insurance policies that provide for medical or hospital expenses shall include coverage for fertility care services, including IVF and standard fertility preservation services for individuals who must undergo medically necessary treatment that may cause iatrogenic infertility. Such benefits must be provided to the same extent as other pregnancy-related benefits and include intrauterine insemination, assisted hatching, cryopreservation and thawing of eggs, sperm, and embryos, cryopreservation of ovarian tissue, cryopreservation of testicular tissue, embryo biopsy, consultation and diagnostic testing, fresh and frozen embryo transfers, and six completed egg retrievals per lifetime, with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine, using single embryo transfer when recommended and medically appropriate.
Group insurers and HMOs that provide pregnancy-related coverage must provide infertility treatment, including diagnosis of infertility, IVF, uterine embryo lavage, embryo transfer, artificial insemination, GIFT, ZIFT, and low tubal ovum transfer. Coverage for IVF, GIFT, and ZIFT is provided if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly infertility treatments covered by insurance. Each patient is covered for up to four egg retrievals. However, if a live birth occurs, two additional egg retrievals will be covered, with a lifetime maximum of six retrievals covered.
Insurers may choose to include other infertility procedures or treatments under the IVF benefit. However, experimental fertility care services, monetary payments to gestational carriers or surrogates, or the reversal of voluntary sterilization are not covered. Religious employers may be exempt from offering fertility preservation services.
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Precertification is required for coverage
Precertification, also known as preauthorisation, is a requirement for coverage in some cases. It is a process that involves a review to determine whether the requested service, procedure, prescription drug, or medical device meets the company's clinical criteria for coverage. In the context of IVF, precertification may be required by your insurer to ensure that the procedure is medically necessary. This means that your doctor has determined that IVF is the best course of treatment for your specific situation and that other, less expensive, and medically viable treatments are unlikely to be successful.
The precertification process can vary depending on your insurance provider and your location. In some cases, your doctor or healthcare provider may handle the precertification process on your behalf. It is important to check with your insurance provider to understand their specific requirements and criteria for precertification. Failure to obtain precertification may result in your insurance company denying coverage for the procedure.
When seeking precertification for IVF, it is important to provide detailed medical records and documentation supporting the medical necessity of the procedure. This may include information about your medical history, previous treatments, and the reasons why IVF is the recommended course of treatment. It is also essential to ensure that the IVF procedure is performed at a facility that meets the requirements of your insurance provider. Some insurers may require the facility to be licensed or certified by the state and conform to specific guidelines, such as those set by the American Society of Reproductive Medicine (ASRM) or the Society of Reproductive Endocrinology and Infertility.
It is worth noting that even with precertification, there may be limits to the coverage provided by your insurance for IVF. These limits can include a maximum number of cycles, such as two or three cycles, or a lifetime maximum coverage amount. Additionally, you may still be responsible for cost-sharing, including deductibles, copayments, and coinsurance, depending on the specifics of your insurance policy. Therefore, it is crucial to carefully review your insurance policy and understand the extent of your coverage for IVF procedures, even with precertification.
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Infertility treatments are often not covered
In the United States, only one state requires coverage under Medicaid, and very few states require private insurance plans to cover infertility services. This means that even if someone has health coverage, they may not be covered for fertility treatments. Additionally, employers who self-insure are generally exempt from the requirements of the law to provide coverage.
In some cases, insurance may cover standard fertility preservation services when a medical treatment may cause iatrogenic infertility, which is when an individual's fertility is impaired by surgery, radiation, chemotherapy, or other medical treatments. This includes the collection, freezing, preservation, and storage of ova or sperm, prescription drugs, and other standard services. However, this does not include the reversal of voluntary sterilization.
In terms of IVF specifically, some large group comprehensive health insurance policies may cover three cycles of IVF and the prescription drugs required for the treatment. However, this is usually only after other basic infertility treatments have been attempted and deemed unsuccessful. Additionally, insurers are not required to cover storage costs under the IVF benefit after the third cycle.
It is important to note that each insurance plan is different, and it is the responsibility of the individual to understand their coverage. It is recommended to call the Member Services number on the insurance card or refer to the benefit plan documents to determine if infertility care is covered.
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Out-of-pocket costs vary by patient and state
The cost of IVF varies depending on the patient's insurance coverage, their circumstances, and their state. In the US, the average cost of a single IVF cycle is over $20,000, but it can range from $15,000 to $20,000, and can exceed $30,000 if a donor egg is involved. The cost can also be impacted by the use of a surrogate or gestational carrier.
The number of employer health insurance plans that cover infertility treatment is growing, but 29 states do not require private insurance to cover IVF treatment. Only 15 states require insurance to cover fertility treatments, and some states have laws mandating that fertility treatments be covered, either fully or partially, by insurance. However, even in states where insurance coverage is mandated, restrictions might force patients to pay for fertility services or birth control out of pocket. For example, in Connecticut, there is a lifetime maximum coverage of two IVF cycles.
The cost of IVF can also vary depending on the patient's circumstances, such as whether they require donor eggs or sperm, and their insurance coverage. For example, a couple with insurance coverage through an energy company paid $2,700 as their out-of-pocket maximum under their policy for one round of IVF. However, they ended up paying more than $15,000 for two rounds of IVF, including all medicines. Another patient, Kaminski, was billed more than $6,000 by the clinic and its surgery center because her care was deemed out of network by Blue Cross. She also incurred nearly $4,000 in out-of-pocket drug costs.
Out-of-pocket costs for IVF can be significant, and it is important for patients to understand their insurance coverage and potential costs before undergoing treatment.
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Frequently asked questions
In the US, some medical insurances do cover IVF, but it varies by state and insurance provider. In 2019, New York passed a bill to require IVF coverage for comprehensive private health insurance policies. A handful of other states also require coverage of fertility services for some fully-insured private plans. However, these requirements do not apply to self-funded plans administered by employers.
You can call the Member Services number on the back of your insurance card. You can also refer to your benefit plan documents for details regarding infertility coverage.
If your insurance does not cover IVF, you may have to pay out of pocket. You can also look into financing options to help manage and reduce fertility treatment costs.
If IVF is not covered by your insurance, other treatments such as intrauterine insemination (IUI), artificial insemination, or prescription fertility medications may be covered.
