Alyssa Lane
The cost of fertility treatments can be very expensive, and many patients lack access to fertility services due to their high cost and limited coverage by private insurance and Medicaid. As a result, many people who use fertility services must pay out of pocket, even if they are otherwise insured. However, 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. In addition, some health insurance plans may cover testing and treatment up to and including intrauterine inseminations, but they will not cover IVF.
| Characteristics | Values |
|---|---|
| Infertility treatment coverage | Required by some states for specific health plans, but not by federal law |
| IVF coverage | Not required by federal law; required by some states for specific health plans |
| Cost of a single IVF cycle | $15,000 to $30,000 without insurance |
| Self-funded coverage | Employers pay for health care services instead of an insurer |
| Religious organizations | Exempt from coverage requirements |
| Self-insured employers | Generally exempt from coverage requirements |
| Small employers | May be exempt from coverage requirements |
| Discrimination protections | Prohibited based on age, sex, sexual orientation, marital status, or gender identity |
| Coverage for fertility preservation | Required by some states for specific health plans if medical treatment may cause infertility |
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What You'll Learn
Infertility treatments and their costs
Infertility treatments can be expensive, and their costs vary depending on the type of treatment and the location of the clinic. In the US, the cost of fertility treatments can be covered by insurance, but this depends on the state and the insurance plan. Some states have laws requiring certain health plans to cover at least some infertility treatments, while others leave it up to employers to decide whether to include infertility coverage in their employee health benefit packages. Self-funded plans, where the employer pays the claims instead of an insurer, are usually exempt from these requirements.
The cost of fertility treatments can range from a few thousand dollars to several thousand dollars, depending on the type of treatment and the number of cycles required. For example, the median cost per IVF cycle in the US was estimated to be $9,226 in 2001, with more recent estimates ranging from $12,500 to $13,800. The cost per IVF birth is significantly higher, with estimates ranging from $41,132 to $61,377. These costs can add up quickly, especially if multiple cycles are needed.
Some insurance plans may cover basic infertility treatments, such as intrauterine insemination, diagnosis and treatment of correctable medical conditions causing infertility, and fertility preservation services when a medical treatment may cause iatrogenic infertility. Large group comprehensive health insurance plans may also cover a limited number of IVF cycles (usually three) and the prescription drugs associated with the procedure.
It is important to note that even when insurance coverage is available, certain types of fertility services (e.g., testing) are more likely to be covered than others (e.g., IVF). The utilization of fertility services has also been impacted by the COVID-19 pandemic, with many patients lacking access due to high costs and limited coverage. As a result, many individuals have had to pay out of pocket for their treatments, even if they have insurance.
When considering infertility treatments, it is essential to research the costs and success rates of different clinics to make informed decisions. Some clinics offer financing plans or risk-sharing programs to help reduce the financial burden on patients.
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IVF and other fertility treatments
The high cost of fertility treatments means that many patients are unable to access them. However, some insurance providers do cover fertility treatments, and it is important to consult your specific insurance policy or provider to understand the extent of the coverage.
In the US, 15 states have laws requiring certain health plans to cover at least some infertility treatments, but these requirements do not apply to self-funded employer-sponsored health insurance plans, which cover 61% of workers.
Some states have specific requirements for the benefits covered by their Medicaid programs. As of January 2020, New York was the only state that required its Medicaid program to cover fertility treatment, but this was limited to three cycles of fertility drugs. No state Medicaid program covers artificial insemination (IUI), IVF, or cryopreservation.
Large group comprehensive health insurance policies in New York must cover three cycles of IVF and prescription drugs for the treatment. New York has also passed a bill to require private health insurance policies to cover IVF and fertility preservation services, with an estimated increase in premiums of 0.5% to 1.1%.
Basic infertility treatments, such as intrauterine insemination, must be covered under individual, small group, and large group comprehensive health insurance policies when the policyholder meets the definition of infertility.
Employers may also offer fertility benefits, which can cover various aspects of fertility treatment, including diagnostic tests, medications, IVF procedures, egg and sperm freezing, and even gestational surrogacy arrangements.
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Fertility preservation services
In the US, as of January 2020, only New York State requires its Medicaid program to cover fertility treatment, limited to three cycles of fertility drugs. However, a handful of states require coverage of fertility services for some fully-insured private plans. Fifteen states have laws in effect requiring certain health plans to cover at least some infertility treatments.
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Religious and employer exemptions
In the United States, there is no federal mandate requiring private insurers to provide infertility benefits. However, some states have laws that require insurers to cover the diagnosis of infertility, treatment of infertility, and/or fertility preservation services. These laws vary widely in their applicability and scope. For example, in Ohio and West Virginia, the requirement to cover infertility services only applies to health maintenance organizations (HMOs). In Arkansas, individual and group policies that offer maternity benefits must cover IVF, but HMOs are exempt from this requirement.
When it comes to religious and employer exemptions, there are several factors to consider:
Religious Exemptions:
- Religious organizations are generally exempt from providing coverage for infertility treatments. This includes religious employers, such as churches or religious non-profit organizations.
- The US Supreme Court decision in Burwell v. Hobby Lobby in 2014 granted certain for-profit employers a religious exemption from providing coverage for contraceptive methods, services, and counseling. This decision has implications for other healthcare services beyond contraception.
- Religious exemptions can interfere with the patient-clinician relationship and informed consent process. For example, some employers may object to covering counseling and education pertaining to contraceptive methods, potentially limiting the ability of clinicians to provide comprehensive care and patients to make informed decisions.
- Religious exemptions can also create confusion for clinicians, who must navigate complex insurance policies. This may result in patients receiving prescriptions or treatments that are not covered by their health plan, leading to unexpected financial burdens.
Employer Exemptions:
- Employers who self-insure are typically exempt from the requirements to provide coverage for infertility treatments.
- Employers with fewer than 50 employees (or fewer than 25 employees, according to some sources) are generally not required to provide coverage for infertility treatments.
- In states with infertility coverage mandates, employers often have the discretion to decide whether to provide these benefits to their employees. For example, in California and Texas, insurers that offer group health plans must offer coverage for infertility treatment, but employers can choose whether to include this coverage for their employees.
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State-specific insurance laws
California
California has a law that requires insurance companies to offer coverage for infertility treatments. However, this does not include in vitro fertilization (IVF) procedures. Employers are not mandated to choose insurance plans with this coverage, and self-insured employers are exempt from the requirements of the law.
Texas
Texas requires insurance companies to offer coverage for infertility treatments, including IVF. Similar to California, employers in Texas are not obligated to select insurance plans with this coverage, and self-insured employers are exempt.
New Jersey
New Jersey laws mandate that group insurers, HMOs, the State Benefits Program, and the School Employees Health Benefits Program that cover more than 50 people and provide pregnancy-related coverage must also provide coverage for infertility diagnosis and treatment. Religious employers, employers with fewer than 50 employees, and self-insurers are exempt from this requirement.
New York
New York does not require individual or small group markets to cover IVF treatments, and self-insurers are exempt from the state's coverage laws. However, it prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition solely because it results in infertility.
Ohio
Ohio mandates that HMOs provide "medically necessary" infertility services, but IVF is not required by law. Self-insured employers are exempt from this mandate.
Colorado
The Colorado Building Families Act provides coverage for medically necessary fertility preservation treatments, including freezing sperm, eggs, or embryos before medical procedures that may impact fertility. This coverage is required in commercial insurance plans in the large group market, and self-insured employers are exempt. Additionally, Colorado requires individual and group health benefit plans to cover infertility diagnosis, treatment, and fertility preservation for iatrogenic infertility, which refers to infertility caused by medical interventions.
Connecticut
The Connecticut Law states that medically necessary expenses for the diagnosis and treatment of infertility must be covered by health insurance companies.
Maryland
The Maryland Insurance Article Section 15-810, "Benefits for In Vitro Fertilization," requires health and hospital insurance policies issued within the state to cover fertility medications without imposing restrictions or limitations different from those for other prescription medications. Religious organizations and self-insured employers are exempt from this requirement.
Montana
Montana requires HMOs to cover fertility treatment, with exemptions for religious employers and self-insurers.
Rhode Island
Rhode Island mandates that insurers, including HMOs, provide coverage for infertility treatments to women between the ages of 25 and 42. Self-insured employers are exempt from this requirement.
West Virginia
West Virginia requires HMOs to provide fertility treatment coverage, with self-insured employers being exempt.
It is important to note that these laws are subject to change and may not be exhaustive. Additionally, eligibility for coverage may depend on various factors, including the duration of infertility, age limits, and specific definitions of infertility used by insurance companies.
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Frequently asked questions
It depends on the state and the insurance provider. As of September 2023, 21 states and the District of Columbia have passed fertility insurance coverage laws. However, only 15 of those laws include IVF coverage, and some states have discriminatory laws that exclude LGBTQIA+ couples and single parents.
Basic infertility treatments, such as the diagnosis and treatment of correctable medical conditions causing infertility, are covered by most individual, small group, and large group comprehensive health insurance policies. Large group comprehensive health insurance policies must also cover three cycles of in-vitro fertilization (IVF) and prescription drugs that are prescribed for the IVF treatment.
Outside of state-mandated situations, it is common for plans to exclude IVF or to have a lifetime maximum benefit. Some insurance plans only cover tests, while others cover tests and IVF cycles. In some cases, insurance will cover testing and treatment up to and including intrauterine inseminations, but they will not cover IVF.
