Infertility Treatment: What's Covered By Insurance?

Infertility treatment is not considered one of the ten essential benefits, and coverage for it is not mandated by the ACA or any other federal law. However, as of September 2023, 21 states and Washington, D.C. have passed fertility insurance coverage laws, 15 of which include IVF coverage.

Infertility treatment is covered by insurance much less commonly than testing. Outside of a state-mandated situation, when there is coverage for infertility treatment, it is fairly common to exclude IVF or to have a lifetime maximum benefit.

In the US, infertility is looked at by insurance carriers more as a social issue rather than a medical issue and can be added to health insurance plans as an 'extra'.

Infertility treatment and insurance coverage

Infertility treatment is not considered a "medically necessary" procedure by insurance companies and is therefore not typically covered by insurance. However, this is changing, with 21 US states and Washington, D.C., now mandating some form of infertility coverage.

Infertility is defined as the inability to conceive a child after one year or more of regular unprotected sex. It can affect both men and women and is classified as either primary or secondary infertility. Primary infertility refers to couples who cannot conceive despite regular unprotected sex for a year, while secondary infertility refers to couples who were previously able to conceive but are now unable to.

Health insurance plans typically do not cover infertility treatment. However, new-age insurers are beginning to design plans that include infertility treatment coverage or offer it as an add-on. Some plans link infertility treatment cover with maternity cover, but the scope of coverage varies.

In the US, as of September 2023, 21 states plus Washington, D.C., have passed fertility insurance coverage laws, 15 of which include IVF coverage, and 17 cover fertility preservation for iatrogenic (medically-induced) infertility.

Causes of infertility

There are various reasons for infertility, including excessive alcohol consumption, unhealthy eating habits, reproductive conditions, irregular sleep patterns, advancing age, and frequent use of emergency contraception.

Types of infertility treatment covered by insurance

Some popular infertility treatments that may be covered by insurance include:

• In Vitro Fertilisation (IVF)
• Intrauterine Insemination (IUI)
• Gamete Intrafallopian Transfer (GIFT)
• Intracytoplasmic Sperm Injection (ICSI)

Factors to consider when buying insurance for infertility treatment

When considering insurance for infertility treatment, it is important to check the terms and conditions of the plan carefully. Here are some key points to consider:

• Check if the cost of fertility diagnosis is covered.
• Understand the eligibility criteria.
• Verify the treatment procedures covered.
• Check the sub-limits and extent of coverage.
• Inquire about the waiting period for infertility treatment, as it can vary between insurers.
• Confirm if prescribed medication is also covered.
• Explore if add-on covers other types of infertility treatment procedures.

IVF is generally not considered a necessary treatment and is, therefore, not covered by most insurance policies. The cost of IVF treatments is typically borne by the couples undergoing the procedure. However, there has been a recent shift, with some companies now covering certain IVF procedures.

Best insurance providers for infertility treatment

When choosing an insurance provider for infertility treatment, it is important to evaluate coverage, out-of-pocket costs, provider networks, and third-party ratings. Here are some recommended options:

• Blue Cross Blue Shield: Offers the most coverage at the lowest price in many states, with ACA plans that cover diagnostic services and treatments, including IVF and embryo transfer.
• Kaiser Permanente: Has the highest NCQA rating for quality and customer satisfaction and offers relatively low out-of-pocket costs for infertility treatment.
• UnitedHealthcare: Provides access to a large network of providers and certain plans offer fertility nurses for one-on-one consultations.

While insurance coverage for infertility treatment is improving, it is essential to carefully review the terms and conditions of any insurance plan to understand the specific coverage offered.

State-specific insurance coverage for infertility treatment

As of late 2023, 21 states and Washington, D.C. have passed laws requiring at least some coverage for infertility treatment on at least some state-regulated health plans. These include:

• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Hawaii
• Illinois
• Kentucky
• Maine
• Maryland
• Massachusetts
• Montana
• New Hampshire
• New Jersey
• New York
• Ohio
• Rhode Island
• Texas
• Utah
• West Virginia

The laws and the extent of coverage vary from state to state. For example, in California, Illinois, New Hampshire, and Texas, coverage for infertility treatment is only required on group plans and not on individual policies. In some states, the mandate only applies to large group plans, such as in Colorado.

Some states have more extensive coverage than others. The states with the strongest mandates are generally thought to be Massachusetts, Illinois, Connecticut, Rhode Island, and New Jersey. In these states, the patient's insurance may cover close to 100% of the treatment costs. However, in states with weaker mandates, patients may still face large out-of-pocket costs.

It is important to note that these state laws only apply to state-regulated plans. If a business self-insures its employees' coverage, the plan is regulated by the federal government, and state regulations do not apply. Additionally, many states that mandate infertility coverage have exemptions for small businesses with fewer than 50 or 25 employees. Religious organizations are also often exempt from providing infertility treatment coverage.

While the Affordable Care Act (ACA) does not require insurers to offer coverage for infertility treatment, many employers, especially large employers, have opted to include coverage for infertility treatment in their group health plans as a way to recruit and retain employees.

Infertility treatment costs and insurance

The cost of infertility treatment can be a significant financial burden, often amounting to more than $10,000 depending on the services received. In the US, fertility care is inaccessible to many due to the high cost and the fact that fertility services are rarely covered by public or private insurers.

Insurance coverage for infertility treatment

As of September 2023, 21 states plus Washington, D.C., have passed fertility insurance coverage laws, 15 of which include in vitro fertilisation (IVF) coverage, and 17 cover fertility preservation for iatrogenic (medically-induced) infertility. However, these laws and the extent of coverage vary from state to state.

In states without any infertility coverage mandate, most insurance plans do not help with the payment for fertility and IVF services. IVF insurance coverage is less common than coverage for other fertility services as it is more expensive.

Factors affecting insurance coverage

Insurance coverage for infertility treatment depends on various factors, including:

• State regulations: Some states have enacted laws requiring health plans to cover infertility treatment, while others have benchmark plans that include infertility-related coverage. However, these laws and mandates may only apply to certain insurers, treatments, or patients, and may have monetary caps or other restrictions.
• Type of insurer: The type of insurer also plays a role, as self-insured or self-funded insurance plans are often exempt from state insurance laws and mandates.
• Employer-sponsored plans: Large employers are more likely to include fertility benefits in their health plans, and some companies even offer specialised fertility insurance plans.
• Individual plans: In some states, individuals can choose insurance with fertility services through the Health Insurance Marketplace, but this is not available in all states.

Choosing the right insurance plan

When considering insurance plans for infertility treatment, it is important to evaluate the following factors:

• Coverage: Find out exactly what is covered, including diagnostic services, medications, procedures, and any criteria that must be met.
• Providers in the network: Ensure that your chosen fertility centres and associated facilities are in-network to avoid unexpected out-of-network costs.
• Copays, limits, and deductibles: Understand your out-of-pocket costs, including deductibles, copays, and coinsurance for fertility care. Also, check for any dollar limits or restrictions on the number of rounds or attempts covered.

Examples of insurance providers offering fertility coverage

Some of the major health insurance providers that offer fertility insurance include:

• Blue Cross Blue Shield: Offers the best average cost scores for premiums, deductibles, and copays. Provides a nationwide list of Blue Distinction Centres for Fertility Care providers.
• Kaiser Permanente: Has the highest rating from the National Committee for Quality Assurance (NCQA) and offers relatively low out-of-pocket costs for infertility treatment.
• UnitedHealthcare: Offers access to a large network of providers, including dozens of Fertility Solutions Centres of Excellence. Provides access to fertility nurses for one-on-one consultations.

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Infertility treatment costs

Insurance coverage for infertility treatment

Factors affecting insurance coverage

Choosing the right insurance plan

Examples of insurance providers offering fertility coverage

Insurance coverage for diagnostic services

• State-Specific Mandates: As of September 2023, 21 states, including Washington, D.C., have passed laws mandating fertility insurance coverage. These laws differ in the scope of coverage, with 15 states including in vitro fertilization (IVF) coverage and 17 states covering fertility preservation for iatrogenic (medically-induced) infertility.
• Diagnostic Services Covered: Insurance plans may cover diagnostic services to varying degrees. Some plans may pay for all diagnostic services, while others may not provide any coverage. Health insurance plans commonly cover services related to testing for infertility. However, once a diagnosis is established, coverage for fertility-related services may cease.
• Grey Areas in Coverage: There can be ambiguity in coverage for certain tests. For example, a hysteroscopy performed to investigate heavy periods and menstrual cramps in a woman trying to conceive may be covered by insurance, but the insurance company might reject payment if they consider it an infertility-related procedure.
• Diagnostic Services and Self-Insured Plans: It is important to note that self-insured plans are exempt from state insurance laws, and employers are not required to follow the mandates. Therefore, if your employer is self-insured, the protections offered by your state's infertility insurance law may not apply.
• Diagnostic Services and Medicaid: Medicaid coverage for fertility services is limited. While some states include diagnostic services in their Medicaid plans, there is no coverage for artificial insemination or IVF under Medicaid.
• Diagnostic Services and Private Insurers: Private insurance plans vary in their coverage of diagnostic services. Some states have laws mandating certain private insurers to cover specific diagnostic services, but these laws may have exemptions for small employers or religious organizations.
• Diagnostic Services and LGBTQ+ Individuals: LGBTQ+ individuals may face barriers in accessing diagnostic services as they often do not meet the definitions of "infertility" required for coverage. Transgender individuals undergoing gender-affirming care may not meet the criteria for "iatrogenic infertility" to qualify for covered fertility preservation.
• Diagnostic Services and Racial and Ethnic Minorities: Racial and ethnic minorities may face disparities in accessing diagnostic services. Fewer Black and Hispanic women report using medical services to become pregnant compared to White women. This is influenced by factors such as lower incomes, barriers, and misconceptions about fertility care.

Insurance coverage for fertility preservation

Private Insurance Coverage

Fertility preservation is a new niche in medicine, and therefore, coverage is limited. Some fertility preservation methods may be covered, like ovarian shielding or radiation shielding of gonads, because they are considered part of radiation treatment. However, standard infertility coverage can sometimes be applied to fertility preservation.

In the US, 15 states require some private insurers to cover some fertility treatment, but significant gaps in coverage remain. As of September 2023, 21 states plus DC have passed fertility insurance coverage laws, 15 of which include IVF coverage, and 17 cover fertility preservation for iatrogenic (medically-induced) infertility.

Some states require coverage of fertility preservation services for women and men who will experience "iatrogenic infertility," meaning infertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment. Note that some states only cover fertility preservation (sperm or egg retrieval) while others cover additional services such as In Vitro Fertilization (IVF).

Medicaid Coverage

Medicaid coverage for fertility preservation is even more limited. Only one state Medicaid program covers any fertility treatment, and no Medicaid program covers artificial insemination or in-vitro fertilization.

Employer-Sponsored Insurance Coverage

Large employers are more likely than smaller employers to include fertility benefits in their employer-sponsored health plans. However, coverage is higher for diagnostic evaluations and fertility drugs than for treatment services such as IUI, IVF, or egg freezing.

Other Options

If you do not have insurance coverage for fertility services, you should ask about fertility preservation discounts. Many clinics will provide significant cost reductions for patients who need fertility preservation procedures. In addition, some hospitals and adolescent & young adult (AYA) programs have charitable funds available to help offset sperm banking and other preservation costs. There are also grants and discounts available through established financial assistance programs.

Frequently asked questions