State Laws Related to Insurance Coverage for Infertility Treatment

Within the United States, around 12% of women have received assistance with infertility.  The definition of infertility is one year of unprotected, frequent intercourse without conception.  Often the solution for infertility is treatment involving various hormone and insemination techniques or therapies.  Within the realm of Assisted Reproductive Technology (ART) there are a variety of ways to attempt a pregnancy, although the most common is fertilization outside of the womb and placement into a uterus through In Vitro Fertilization (IVF).  There is a large amount of children born in the US each year as a result of ART procedures.  In 2008 there were nearly 62,000 babies born from non-donor In Vitro Fertilization and the Center for Disease Control estimates that ART procedures result in just about 1% of births in the US. While many of these births through ART attribute to many multiple births, which results in many premature births than through single births.

With advances in the industry, infertility treatments have helped thousands of people become parents or grow families, although these procedures often are without much stress and controversy.  The main drawback to using these procedures is the cost, estimating that average cycles of IVF can cost anywhere between $8,000-$16,000 for procedures with medications.

Overview of Laws Related to Infertility Treatment

Fifteen states in the US have passed laws requiring insurers to completely cover or at least offer some coverage for infertility diagnosis’ and treatments. The 15 states being West Virginia, Texas, Rhode Island, Ohio, New York, New Jersey, Montana, Massachusetts, Maryland, Louisiana, Illinois, Hawaii, Connecticut, California, and Arkansas. Within these 15 states, there are varying coverages in regards to infertility. The two states of Louisiana and New York have laws that exclude coverage for a condition that would otherwise be covered, only because the condition results in infertility and in California and Texas, laws protect coverage directly for infertility treatments.  California laws surrounding infertility protect the right to treatment without discrimination, offering individuals and families to seek out assistance. In the state of Utah, insurers are able to provide coverage for maternity benefits and indemnity benefits for adoptions or ART treatments. While most of the states have laws that require insurance providers to offer coverage, California, Louisiana and New York specifically exclude the procedure of In Vitro Fertilization.

What kinds of treatments related to ART are covered by insurance?

In many cases, the best steps for those interested in researching their insurance options, are to learn their individual options within ART and IVF.  Within the healthcare insurance system it can be very difficult to find coverage.  Purchasing an individual health insurance plan often does not work for ART unless the state you’ve purchased it in is required by law to provide treatments and even in the highest coverage state, does not require coverage of IVF.  All states including those with partial coverage of treatment often make exceptions for medically necessary conditions. In many cases a medically necessary condition can be defined as medical services needed to diagnose and treat an illness, condition, disease or symptom. And under the Affordable Care Act, coverage for pre-existing conditions should have no wait time.  While plans are likely to pay with no waiting period for medically necessary conditions, there are common conception disorders that may fit into the category of coverages provided by a healthcare insurance provider.

  • Sexually Transmitted Diseases are a common covered item that includes blood tests, isolating bacteria. Diseases within this category are Chlamydia and Gonorrhea which are commonly understood to lead to Pelvic Inflammatory Disease.  These tests and antibiotics are often covered under health insurance plans.
  • Endometriosis which is a cause of very painful menstrual cramps, symptoms of digestion and gastro-intestinal symptoms or fatigue. Services are often covered that include Pelvic exams for cysts and scars, ultrasounds, hormone therapy and in some cases a conservative laparoscopic surgery.
  • Polycystic Ovarian Syndrome (PCOS) is an imbalance of hormone production which can often cause weight gain, fatigue, hair growth, often leading to diabetes and/or high blood pressure. Many insurance companies cover services for PCOS which can include hormone therapy. In some cases PCOS is related to smoking, and often a Smoking Cessation therapy program may be covered.
  • Uterine Fibroids that affect the endometrial cavity, ultimately affecting conception, can be covered for services using a regulation or hormones and menstrual cycles. This is often a non-invasive and traditional style of surgical procedures.
  • Hyperthyroidism (overactive) or Hypothyroidism (underactive) both prevent ovulation, therefore causing infertility, often the covered services for these include diagnosis using blood tests and treatment of drug therapies.

The Loopholes of Insurance and Mandated States

When searching for individual health insurance plans, it is often very difficult to find verbiage that specifically covers ART procedures.  Because reproductive services are not considered medically necessary, many health insurance companies avoid the added financial risks involved, especially with the uncertain outcomes.  Another reason insurance companies do not find ART procedures necessary is because these procedures do not cure an illness, relieve pain or restore and sustain life.  However, many people across the US have insurance plans that cover one or more assisted reproductive technology procedures. Some individuals that live or work in a non-mandated state, could still benefit from researching where their health insurance plan through their job is written.  The state in which the policy of the company was written, determines which legal directive and statutes apply to the holder.  For example, if the policy written in mandate states, but the company holds satellite offices in non-mandate states workers can benefit from coverage even in non-mandated states.  If you live in a non-mandate state, but are able to find employment with a company that’s policy is written in a mandate state, it may be to your benefit to gain employment with them as their mandate state policy can offer more benefits of ART.  In some cases, these employers pay less, but it may be to your benefit if they cover multiple rounds of IVF cycles.

Couples that live in non-mandated states can find those nationwide employers with health insurance coverage for IVF treatments, can find solace in the fact that there are many companies in which employment may be possible in order to gain the IVF benefits of coverage. In some cases, you may work for a company that provides an Flexible Spending Account (FSA) along with your health insurance coverage, in that case it may already be a benefit to use this account as a way to alleviate the strain of IVF treatments. The following employers offer a variety of different coverages that pertain to Infertility, ART and in some cases cover part of IVF.

  • Federal Government: This is the largest nationwide employer within the US.  The Office of Personal Management (OPM) generally offers benefits that may not be required by law in order to stay as up-to-date as possible with private industry companies and employers.  Many of the federal plans will cover both the diagnosis and certain treatments for infertility for employees working in non-mandated states, this is specifically designed to compete with private companies for skilled workers. Many of the items covered under employment with the Federal Government is Artificial Insemination, Intravaginal insemination, Intracervical insemination, intrauterine insemination, fertility drugs both injectable and oral.  The excluded benefits are IVF, the embryo transfer, GIFT, services and supplies related to many ART treatments, and the payments for donor sperm.
  • State Government: Employment within each state is the second largest public employer. Similarly offering a coverage for a variety of treatments, each varying state by state. Because state employees are unionized, many of their collective agreements from bargaining can result in some awesome coverages for assisted reproductive technologies, and often this includes non-mandated states.
  • Armed Forces: Many military service members can find benefits for their families in the following three service providers:
  • Tricare: This company covers infertility diagnosis and procedures, and in the cases of injury in the line of service, will cover such services as IVF and artificial insemination.
  • The Veterans Health Administration (VA): Coverage for infertility assessment, treatments and counseling for both female and male veterans.
  • The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): Offers an extensive health care program that covers many services and supplies involving infertility testing, diagnosis and treatment.

Aside from the public facility employer, there are many privately owned companies that have a similar competitive coverage plan for their employees. Private companies are often subjected to their legal requirements, and in some cases do not provide any coverages for infertility, ART or IVF due to their private privileges are not required to by law.  Although, in many cases private companies are looking to compete for skilled workers as well and can go to many lengths in order to offer employees infertility and ART coverages.  The most likely of industries to offer extensive coverages are Information Technology companies, Accounting and Financial industry companies, and the Medical industry.  The companies that are least likely to offer coverage or partial coverage are retail, food services and the hospitality industry. Although many companies fall into these respective categories, there are still benefits to looking further into the health insurance benefits a company provides before making a decision on employment. Here are a few surprising companies you may want to look into if you’re interested in gaining more coverage from an employer:

  • Boeing: Their Health Insurance policy is written in Washington State, which allows them to offer benefits for ART.
  • Costco: While IVF is not fully covered, many of the diagnosis of infertility and treatment for underlying conditions can be covered. Their policy is also written in Washington State which allows them to provide more coverages.
  • The Disney Company: This company has a variety of related infertility treatment coverage plans, although because of the legal directives provided from the different states under which the policies are written, it varies from state to state.
  • Fedex: Headquartered in Tennessee, and does not have a legal mandate there are higher benefits for high-skilled laborers, technicians and pilots while lower-skilled jobs still are provided partial coverages for ART related services.
  • Starbucks: Headquartered in Washington State, with no legal mandate is able to offer $20,000 for IVF treatments, and many other ART procedures. This is specifically designed to entice employees.
  • UPS: headquartered in Georgia, which is another non-mandated state covers many options for diagnosis of infertility along with medical treatments to correct it. They do not, however, cover treatment that is indented to produce a pregnancy.

Insurance Providers that cover treatment of infertility, ART, and IVF

Many couples and individuals who prefer to find an individual health insurance company to cover infertility and IVF my struggle with this as well.  Often businesses and companies will opt to not provide coverage for ART or IVF treatments, unless mandated by the law in the state in which they operate.  Couples may find that researching the coverages of each specific health insurance company may create confusion, since the names, categories of coverages, and titles of treatments listed can vary in meaning.  The large and public health insurance companies such as Medicaid and Medicare will be provided by private companies as supplemental plans although their program names are confusing and have vague answers of coverage surrounding ART and IVF.  As a general rule, these programs cover mostly basic needs to low-income families, supporting general health and nothing above and beyond that. Private insurance companies often will not pay for ART or the like, especially without a legal mandate, or an employer specifically requiring that option as a benefit.  The reason that private insurance companies are likely not to provide these benefits is that ART is expensive, offering this requires the premiums of their entire network to go up, thus with the efforts to keep all premiums lower, limiting their risk and cost they limit their coverages.  Another reason private insurance companies avoid offering ART and IVF is that it is not considered medically necessary, with the possible side effects of physical pain, and possibility of bodily harm or death, many insurance companies will limit coverage for the full extensive treatments of IVF. The third and final reason ART and IVF are not readily provided under private insurance companies is because of it’s result of pregnancy.  Many of the pregnancies that result from IVF and ART treatments are considered high-risk, with the higher rates of multiple births, meaning that this is more expensive for health insurance providers, and ultimately raises the entire groups premiums.

Get Help from Your Fertility Friend

Insurance for the Outcomes of ART and IVF

While it is well known that often the burden of IVF cycles can be a financial burden on a couple, many individuals forget about the financial aspects of post pregnancy. Ultimately the goal of Assisted Reproductive Technologies and In Vitro Fertilization is the end result of a pregnancy.  Couples who reach this point have already struggled with insurance, deciphered their best plan of action with the benefits of their employers health insurance and often have taken out large loans or dipped into their savings.  It is suggested that thought be put into the post pregnancy phase of the cycle of IVF treatments, as this often poses a financial burden as well. The use of supplemental insurance providers, may be a great option for the mother and couple as many women opt for maternity leave as the baby due date nears.  The other added benefit of supplemental health insurance is for the delivery and hospital expenses that often result in hefty medical bills and any unexpected complications during delivery.