Marcia Passos Duffy - Last updated: May 21, 2010
Infertility carries a steep emotional price. But the high price tag of infertility begins to sink in when you realize your group health insurance policy may not cover the cost of the expensive treatment.
Infertility affects roughly 7.3 million Americans, according to RESOLVE: The National Infertility Association, based in McLean, Va. This figure translates to 1 in 8 couples.
If infertility treatment isn’t covered by your group health insurance, you shouldn't necessarily blame your insurance company.
"The decision [to cover infertility treatments] does not lie with insurance companies. Employers make that decision," says Sean Tipton, public affairs director for the American Society for Reproductive Medicine (ASRM), a non-profit professional medical organization based in Birmingham, Ala.
"Most insurance companies would offer it if their customers -- the employers -- pushed for it," he says.
Tipton says that while there is currently no reliable research on the number of employers who provide infertility treatment benefits in their group policies, anecdotally, the majority of U.S. employers don't voluntarily include it in their health insurance coverage .
"Most employers don't bother unless they are pressured by their employees," says Tipton. Indeed, a 2006 survey commissioned by RESOLVE showed that 65 percent of insurance companies that provide infertility treatment benefits offer it because an employee at a workplace asked for the coverage.
For those who don’t have access to group health insurance, it is be impossible to find individual health insurance plans that cover infertility treatment.
States that mandate infertility insurance
Currently, 15 states have some kind of mandate requiring group health insurers to cover infertility treatment: Arkansas, California, Connecticut, Georgia, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Mexico, New York, Ohio, Rhode Island, Texas and West Virginia.
However, state mandates can be "pretty worthless," notes Tipton. "Some have enormous loopholes."
For example, California, Louisiana and New York do not mandate coverage for in vitro fertilization. In Maryland and New Jersey, the mandate does not apply to companies with fewer than 50 employees; in Illinois, that threshold is 25 employees.
For more details of mandates for each state, visit the Kaiser Family Foundation's state information for insurance coverage for infertility .
Reading the fine print
Even if your state mandates infertility treatments for group health insurance plans, you should still check the fine print in your employer’s health insurance policy (which you may have to ask for). Find out what is covered and how much is covered before you make an appointment to begin treatment. Carefully read the policy for:
- Limits of coverage
- Pre-qualification requirements
As added assurance, call the insurance company and find out specifically which treatments are covered and ask for this information in writing. For example, does the insurance coverage allow the doctor to find out the underlying cause of the infertility? Are specific treatments, such as IUI (intrauterine insemination) and IVF (in vitro fertilization) covered? Are injectible medications covered?
Remember, not everyone can qualify for infertility insurance coverage. Some insurance companies require you to be younger than 40 and you must have faced infertility for one to five years and been a plan member for at least a year.
Some insurers may also refuse to insure people who have been diagnosed with the pre-existing condition of infertility. However, this may change in 2014, once the provision in the new health care reform law outlaws the denial of insurance coverage to those with pre-existing conditions.
If your group policy does not cover infertility treatments, speak with someone in your employer’s benefits department. Ask if it’s possible to add a rider onto your policy to cover treatment. If specific treatments are not covered, you can ask about those as well.
"Coverage for certain types of advanced reproductive technology, such as IVF, may be available if the employer purchases a rider to cover these services," says Dr. Joanne Armstrong, an Aetna U.S. Healthcare senior medical director. Aetna's standard plan covers basic services that are required to diagnose infertility. More advanced services, such as IVF or gonadotropin ovarian stimulation combined with intrauterine insemination, are not standard benefits.
These benefits "are available when employers choose to add it to their benefit plans for employees or when required by state mandates," says Armstrong.
If your employer is not willing to buy a rider for infertility treatment, find out if you qualify for discount programs that exist to help pay for such infertility treatment, such as CVS Caremark’s Fertility Care Program.
Infertility insurance for all?
Even though infertility has been classified as a disease by several medical organizations, Tipton says it has never been treated the same way as other types of diseases.
"There shouldn't be a stigma for suffering from infertility," says Tipton.
Yet public policy makers, employers and insurers do not necessarily view infertility the same way as diabetes or heart disease. Infertility treatments are also fraught with controversy. Some religious groups, including the Catholic Church, oppose fertilization outside the body. Pro-life groups say that some treatments lead to destruction of human embryos -- a practice they argue is indistinguishable from abortion. Many states with mandates do not require religious organizations with group insurance to cover infertility.