By now, you’ve probably read that insurance coverage for treating infertility doesn’t come close to matching the coverage for treatment of other major medical conditions. In the past, the stated reasons for this difference included gender inequities and incorrectly labeling in vitro fertilization (IVF) as “experimental.”
Today, these types of rationales for not including infertility in insurance benefits packages are simply no longer relevant.
The good news is that coverage for infertility treatments is improving. This is especially true for employers who recognize that there is a major return on offering infertility treatment as a covered benefit. Surveys show there’s an enhanced ability to attract and retain the best employees. In addition, worker morale and productivity also improve.
Large employers are leading the way
Large employers are leading the way. The biggest growth in coverage arrived a few years ago, especially in the tech, media, and banking sectors. More recently, the healthcare, insurance, industrial manufacturing, consumer product, and retail sectors have added or improved their coverage.
Infertility benefits for the military vary but there are several options including care at Military Treatment Facilities (MTF) and TRICARE insurance which may be used outside MTFs including at some fertility clinics. The cost of services are often less at MTFs and a number of clinics have established discount programs for military and veterans.
A further challenge for military and vet coverage is that some programs depend on an annual Congressional authorization to continue and fund coverage of these services. This creates a tremendous amount of uncertainty for those facing a diagnosis of infertility.
But there is room for improvement
Across the board, there’s substantial room for improvement. Further, when policymakers don’t think employers, insurance companies or health plans are doing what they should, states may step in and mandate coverage.
States pass mandates because state legislators believe coverage – or adequate coverage – will not likely be offered unless the state requires it. Whether states pass such legislation often depends on who advocates for change.
Given the statistics, you’d think every state would have a mandate in place:
- Infertility affects 1 out of every 6 people according to the WHO, and approximately 7.3 million US women have used infertility treatment to get pregnant, according to the Centers for Disease and Control and Prevention (CDC).
- About 1 in every 55 babies born in the US comes after infertility treatment (CDC).
- The high cost of treatment: a single cycle of IVF starts at around $12,000 and more than half of women require a second cycle. Fertility drugs and tests (such as ultrasound monitoring) can add another $5,000 per cycle. And, donor eggs or sperm and genetic testing may be needed, at additional cost.
- Some employer coverage data suggests that 63 percent of patients and employees receive zero coverage for infertility treatment while nearly 20 percent receive complete coverage.
Fertility Scorecard
There’s a patchwork of coverage mandates, according to RESOLVE: The National Infertility Association. RESOLVE has created a “Fertility Scorecard” and map that ranks each state with a letter grade based on their access to treatment policy. Sadly, less than a handful of states have earned an “A.”
RESOLVE also actively monitors ongoing legislative and regulatory activity. So, the scorecard and map let you know whether your state is moving in a direction that improves or restricts access to coverage for infertility services. CLICK HERE to get involved with RESOLVE’s advocacy work to improve access to care at the state and federal level.
State mandates
Just 17 states require some sort of infertility coverage from insurance companies for those seeking care: Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New Hampshire (effective 2020), New York, Ohio, Rhode Island, Texas and West Virginia, according to the National Conference of State Legislatures (NCSL).
Of those states, all but California and Texas require that insurance companies cover infertility treatment. California specifically excludes IVF from the state mandate. Texas requires only that insurance companies let employers know if coverage is available. The state does not require that either insurance companies or employers must offer the benefit.
In the case of California, legislators this year failed to pass legislation that would require broad coverage of IVF. Instead, they turned to legislation that would clarify that fertility preservation be required as a covered benefit under medically necessary care. This would involve preservation of eggs, sperm, and embryos for those who needed the procedure due to treatment for cancer or another condition that would damage their fertility.
The bill originally would have applied to Medi-Cal beneficiaries – the state program for low-income residents. This provision was removed over budget concerns. Seven states currently mandate such coverage.
Understanding your coverage: the details are important
So, unless you work for a large employer, or in a specific industry, or live in one of the states with a coverage mandate – you may be on your own.
To find out whether you do have coverage for infertility treatment you should contact the HR or benefits manager at your place of work You can also get an explanation of benefits from your health plan by contacting member services. You’ll need to have your employer group number available because plan coverage varies by employers. Employers largely make the decision on what benefits to offer their employees.
It’s also especially important with infertility coverage to find out what restrictions may apply. Sometimes a benefit will only pay for diagnostic tests or for procedures based on pre-authorization requirements. The latter may require a year of failing to get pregnant without assistance. Obviously this is a provision that many single women and same-sex couples will never be able to meet. Such restrictions may leave you having to pay for most of the costs on your own.
Advocating for infertility coverage at work
To help you advocate for infertility coverage at work, RESOLVE has created a program that provides all the information and tools you need including a checklist, letter to your employer, inspiring success stories and more. Check out at Coverage at Work to find the resources you need to make a difference for yourself and your colleagues. ARC Fertility is a proud sponsor of RESOLVE’s work.
Other organizations and fertility clinics are also trying to help fill in the gaps and make treatment more financially accessible for those without coverage or adequate coverage. This ranges from bundled treatment packages to financing for those who meet eligibility requirements.
While these are available to individuals and couples, some organizations have created special employer programs that can make a real difference.
Some organizations offer employer programs
For example my organization, ARC Fertility, offers an employer program to fit employers of all sizes with flexible benefit options. The benefit is provided through ARC member clinics, the largest national fertility network of board-certified specialists at 80 clinics in more than 220 sites across the US.
Each program is custom-designed, and employers have the flexibility to pay partial or full subsidy for care with no per member per month fee, and payment only when services are used. Cost-effective care follows national standards and applies a “Centers of Excellence” approach. Employees benefit from education on healthy reproductive lifestyles and concierge services.
In fact, ARC Fertility was recently granted a Health Value Award by an independent organization focused on improving healthcare and recognizes institutions that provide “better outcomes at a lower cost.” You can learn more about the employer program HERE.
Betsy Campbell of RESOLVE reminds everyone that “You need to be an advocate for yourself when it comes to you and your family.” “This journey,” she continues, “affects people physically, mentally, spiritually, financially and socially.”
It definitely takes work to find the right resources and support along your fertility journey. However, it might be good practice for the day your baby becomes a teenager!
This article was originally published on The Doctor Weighs In.
