Jeffrey Wade
Infertility is a major issue of concern for many couples, with a range of causes from late marriages to obesity and stressful lifestyles. While some insurance companies cover infertility treatments, many do not, and even those that do often have frustrating restrictions. This leaves many patients with high out-of-pocket costs, which can range from a few thousand dollars to $180,000 or more. In the US, state laws vary, with some states requiring insurers to cover infertility diagnosis, treatment, and fertility preservation services, while others do not. Even within states that require coverage, there are often exceptions for certain types of plans, such as self-funded employer plans or HMOs.
| Characteristics | Values |
|---|---|
| High cost of fertility treatments | $5,000 to $180,000+ |
| Limited coverage by private insurance and Medicaid | 15 states have laws requiring coverage |
| Lack of access to fertility services | 83% decrease in patient encounters during COVID-19 |
| Self-funded plans | Employers pay claims instead of insurers |
| Exclusions | Reversal of voluntary sterilization |
| Cost-sharing | Deductibles, copayments, and coinsurance |
| Annual dollar limitations | Varies by state |
| Age restrictions | Not permitted |
| Preauthorization requirements | Allowed |
| Medical necessity reviews | Allowed |
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What You'll Learn
High costs and limited coverage by private insurance and Medicaid
The high cost of fertility treatments and the limited coverage offered by private insurance and Medicaid are significant factors in the lack of insurance coverage for infertility. In the United States, the cost of fertility treatments can be prohibitively expensive for those without insurance coverage. The cost of covering fertility benefits varies depending on the services covered and utilisation, with implications for state budgets, employers, and policyholders. This results in many individuals having to pay out of pocket, even if they have insurance.
The coverage of fertility services by private insurance and Medicaid is limited and varies depending on the state and the specific insurance plan. As of January 2020, only New York required its Medicaid program to cover fertility treatment, limited to three cycles of fertility drugs. No state Medicaid program covers artificial insemination (IUI), IVF, or cryopreservation. A handful of states require coverage of fertility services for some fully insured private plans, but these requirements do not apply to self-funded plans, which cover six in ten workers with employer-sponsored health insurance.
The cost of fertility treatments can vary greatly depending on the specific treatment and the location. For example, the average IVF treatment cost in India can vary significantly from city to city. In the United States, fertility treatments can range from a few thousand dollars to $180,000 or more for pathways such as gestational surrogacy. The high cost of fertility treatments can be a significant financial burden for individuals and couples seeking treatment.
While some states are working towards improving access to fertility treatments, the limited coverage by private insurance and Medicaid remains an issue. For example, California state law will require large-group plans to cover the diagnosis and treatment of infertility, including IVF, starting in 2026. However, this change only applies to fully insured, non-self-insured plans, and there are still exceptions for certain treatments and employers.
Overall, the high costs of fertility treatments and the limited coverage offered by private insurance and Medicaid present significant challenges for individuals and couples seeking treatment for infertility. The lack of standardised coverage across states and insurance plans contributes to the financial burden and restricts access to necessary medical care.
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Exclusion of self-funded plans from state requirements
In the United States, state insurance mandates do not apply to self-insured or self-funded employer plans, which are regulated by federal law. Self-funded coverage means that an employer is responsible for paying the claims for their employees' healthcare services instead of an insurer.
Self-funded plans are administered and funded directly by employers and cover 61% of workers with employer-sponsored health insurance. Therefore, even in states with "mandate to cover" laws, these requirements do not apply to self-funded plans. For example, in Ohio and West Virginia, the requirement to cover infertility services only applies to health maintenance organizations (HMOs).
Some states have laws in effect requiring certain health plans to cover at least some infertility treatments. As of January 2020, only one state, New York, specifically requires its Medicaid program to cover fertility treatment (limited to three cycles of fertility drugs). In 2019, New York also passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies. In California, legislation was enacted in 2024 that will require state-regulated large group plans to cover the diagnosis and treatment of infertility, including IVF, starting in 2026 for calendar-year plans.
While coverage for infertility treatments is expanding in some states, it is important to note that federal law does not require any health plans to cover infertility treatment.
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Employers' discretion in offering infertility coverage
In the United States, there is no federal mandate requiring insurers to cover infertility treatments, and state laws vary widely. While some states have laws requiring certain health plans to cover at least some infertility treatments, these requirements do not apply to self-funded plans administered and funded directly by employers, which cover 61% of workers with employer-sponsored health insurance.
Employers who self-insure are exempt from the requirements of the law and have discretion in offering infertility coverage to their employees. This means that they can choose whether or not to include infertility coverage as part of their employee health benefit package. For example, in California, state law does not require insurers to cover infertility treatment, but it does mandate that insurers offering group coverage must provide coverage for infertility diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT). It is then left to the employer to decide whether to extend these benefits to their employees.
The cost of covering fertility benefits can vary depending on the services covered and utilization, with implications for employers and policyholders. For instance, in 2019, New York passed a bill mandating IVF and fertility preservation services for comprehensive private health insurance policies. As a result, the New York State Department of Financial Services estimated a premium increase of 0.5% to 1.1% for IVF coverage and 0.02% for fertility preservation for iatrogenic infertility. Similarly, an analysis of a proposed bill in California to mandate IVF coverage in private plans and Medi-Cal managed care plans projected a per-member premium increase of approximately $5 in the private market and less than $1 for Medi-Cal plans.
While some employers may choose to include infertility coverage in their health benefit packages, others may opt to offer fertility supplementation or reimbursement separate from their health insurance plans. Additionally, some employers may provide support to employees facing infertility through other means, such as offering a more flexible work schedule, paid time off, or sick days.
It is important to note that the availability of infertility coverage can vary significantly across different employers and insurance plans. As a result, individuals seeking infertility treatment should carefully review their insurance policies and consult with their healthcare providers to understand their coverage options and any applicable restrictions.
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Varying state laws and mandates regarding coverage
The coverage of infertility treatments varies across the United States, with some states requiring certain health plans to cover at least some infertility treatments. These mandates do not apply to self-funded health plans administered and funded by employers, which cover 61% of workers with employer-sponsored health insurance.
State-by-State Mandates
- Arkansas, Maryland, Massachusetts, and New York mandate that individual and group insurance policies that offer maternity benefits must cover IVF treatments. However, HMOs are exempt from this requirement in Arkansas. Maryland limits the lifetime benefit cap for fertility treatments to a maximum of $100,000.
- California will require non-self-insured large group health plans to cover the diagnosis and treatment of infertility, including IVF, from July 1, 2025 (January 2026 for calendar-year plans). Additionally, insurers in California must cover fertility preservation if a covered medical treatment, such as chemotherapy or surgery, is expected to result in infertility.
- New York also mandates coverage for fertility preservation services and requires insurers to cover the costs of oocyte and/or embryo storage in connection with IVF procedures until the third cycle.
- Ohio requires HMOs to cover medically necessary preventive "basic health care services," including infertility services.
Medicaid Coverage
Medicaid coverage of infertility treatments varies by state. As of January 2020, New York is the only state that specifically requires its Medicaid program to cover fertility treatment, limited to three cycles of fertility drugs. While other states may not explicitly mention infertility, they may cover treatments for conditions that impact fertility, such as thyroid medications or surgery for gynecologic abnormalities. No state Medicaid program currently covers artificial insemination (IUI), IVF, or cryopreservation.
Private Insurance Coverage
Private insurance coverage for infertility treatments varies, and some insurance companies require a certain amount of time to pass before infertility coverage can be accessed. Some employers offer fertility supplementation or reimbursement separate from their health insurance plans, and employees may need to purchase additional coverage or riders for infertility treatments.
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Cost-sharing requirements for patients
In other cases, patients may need to purchase additional coverage or a separate package through another provider to access infertility treatments. For instance, some insurance companies require riders to be purchased on top of the current plan to access infertility benefits. Additionally, some employers offer fertility supplementation or reimbursement separate from their health insurance plans.
It is important to note that the cost of fertility treatments can be very expensive, ranging from a few thousand dollars to $180,000 or more for pathways such as gestational surrogacy. Therefore, patients should carefully review their insurance policies and understand their coverage limits and cost-sharing requirements before initiating treatment.
In terms of specific cost-sharing requirements, patients with large group coverage in New York are entitled to embryo storage in connection with an intended in-vitro fertilization procedure if medically necessary until the three required IVF cycles are provided. However, insurers are not obligated to cover storage costs beyond the third IVF cycle. Additionally, in New York, Medicaid specifically requires their program to cover fertility treatment, limited to three cycles of fertility drugs.
Lastly, it is worth mentioning that while some states have laws mandating coverage for infertility treatments, there are exemptions for certain types of insurance plans. For example, small group insurers are not required to offer coverage for IVF, and employers who self-insure are generally exempt from the requirements of the law. Therefore, patients should consult their insurance providers and review their policies to understand their specific cost-sharing obligations for infertility treatments.
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Frequently asked questions
Insurance companies are not mandated to cover infertility treatments and can choose to exclude them from their policies. In the US, only 15 states have laws requiring certain health plans to cover at least some infertility treatments.
Fertility treatments can cost anywhere from a few thousand dollars to upwards of $180,000, depending on the treatment type and location. The high costs are due to the advanced medical procedures, medications, and technologies involved.
Some employers offer fertility supplementation or reimbursement separate from their health insurance plans. Flexible spending accounts or health savings accounts can also be used to pay for fertility treatments. Additionally, some patients may qualify for financial assistance programs offered by fertility clinics or non-profit organizations.
