Couples seeking medical help in order to conceive eventually turn to In Vitro Fertilization (IVF). The procedure is extremely expensive and the results uncertain. They may need multiple cycles. Couples naturally then ask, “What health insurance covers IVF treatments?”
The way they ask the question suggests that education is needed. Most queries include a specific company name. Economics and regulations matter far more than brand name when determining what medical insurance covers IVF treatments.
- Why health insurance rarely covers treatments
- How regulations which plans do provide coverage
- How state regulations apply to specific companies
Health Insurance rarely Covers IVF Treatments
The first thing many couples find is that health insurance covering In Vitro Fertilization treatments is very rare. There are two primary reasons why carriers choose not to make claims payments for any artificial reproductive technique. First, the treatments are elective; there is no medical necessity. Second, the economics just do not work.
With coverage being so rare, couples often find that programs financing IVF treatment costs are the best avenue.
Lack of Medical Necessity
The first reason that health insurance rarely covers IVF treatments is that most carriers view it as an elective procedure. The inability to conceive is not a life threatening condition. A patient’s choice to pursue treatment is a lifestyle choice. Treatments do not result in a cure of a medical condition. Most policies exclude benefits for many elective medical procedures.
Members of the artificial reproductive technique community are lobbying lawmakers to define infertility as a disease, but headway is slow. The economics make this a difficult task.
Economics of Insurance
The second reason why health insurance rarely covers IVF treatments is the economics are bad for carriers. They must bear the cost of the procedure, adverse selection, and downstream expenses.
IVF is very expensive. The average cost of a single cycle is about $15,000. Many couples may need multiple cycles in order to conceive. Carriers dislike paying these very large amounts for elective procedures with indefinite medical necessity.
Medical insurance that covers IVF treatments contribute to adverse selection. Adverse selection is a common phenomenon that hurts profitability, and raises premium rates. Adverse selection occurs when people expecting to utilize the benefits purchase policies. They pay a relatively small premium, and get a much larger benefit payment in return for a certain treatment protocol. When too much adverse selection occurs, the policy premiums must rise for everyone.
Health insurance covering IVF treatments increases downstream medical costs. Infertile couples do not have babies. Pregnancy and childbirth is expensive to insure. Multiple pregnancies are often high risk and deliver preterm. Multiple birth rates for treatments are sharply higher than natural conception. Costs for preemies are ten times that for a normal delivery.
Tricks for Getting Insurance to Cover IVF
Learn how to make getting pregnant via IVF more affordable using insurance.
When Health Insurance Plans do Cover IVF
Despite the lack of medical necessity and bad economics, many health insurance plans do cover In Vitro Fertilization. In the United State of America, state level insurance laws make them do it. Lobbyists convinced regulators that couples unable to conceive should enjoy coverage, even if their medical condition was not life threatening, and even though the issuers would lose money selling the plans.
There are two pieces to the puzzle of finding health insurance plans covering IVF. There are the state regulations, and then there is how the laws apply to each plan.
Fifteen states require that health insurance plans issued in their jurisdiction cover certain infertility treatments. Eight of the mandates include IVF: Arkansas, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, Rhode Island, and Texas.
If you live in one of the eight states with a mandate, your odds of finding a plan are better, but not guaranteed. Each mandate includes exclusions that you need to know. On the other hand, if you live in a non-mandate state you may still be able to find a plan. The mandates primarily apply to group plans sitused in the state.
The situs location or headquarter state for the employer of both spouses is the key to unlocking the door for health insurance plans covering IVF. Several of
the states with mandates house the headquarter locations of many nationwide employers. The group plan purchased in that state must provide mandated benefits to all participants, regardless of where they live.
Couples living in non-mandate jurisdictions may still enjoy benefits if they work for an employer based in a mandate jurisdiction.
Health Insurance Companies Covering IVF
Health insurance companies cover In Vitro Fertilization when the policies they issue must comply with a mandate. The regulations do not directly apply to companies. Rather the mandates apply to the policies themselves. Each company must comply with the applicable mandates, which have exceptions based upon the type of plan, and characteristics of the employer group. Smaller employers, government and religious organization, and self-insured employers are often exempt.
Take these factors and combine them together. Gain some high level insight into whether each health insurance company might offer a policy covering IVF, and whether the combination results in your lucky number.
Health insurance companies covering IVF do so in specific market niches. Some market segments are based on geography, while others have more of an industry focus. By combining the mandates with market segments, you can narrow down the possibilities.
Aetna operates in all fifty states and provides a good example of how mandates are exported out of jurisdiction. A group plan issued by Aetna in New Jersey may be subject to the mandate. Employees of that group working in other non-mandates locations would purchase the same plan, with the same features. For example, any employees living in Arizona, California, Florida, Georgia, New York, Ohio, or Texas would enjoy the same benefits as those living in NJ.
Aflac provides supplemental policies that cover IVF indirectly. They make payments for resulting pregnancies and hospitals stays. Get the policies at work. Purchase before your next cycle.
Anthem Health is a Blue Cross Blue Shield (BCBS) affiliated organization operating in fourteen states. None of these is a mandate jurisdiction.
AXA is a leading provider of life insurance, retirement, and investment plans. They do not appear to offer health insurance.
Aviva is a United Kingdom based organization and not subject to regulations in the U.S.A.
Blue Cross Blue Shield (BCBS) is a national federation of affiliated insurance companies using this trade name. BCBS is actually thirty-seven different independently operating organizations rather than one.
BUPA International is a health services organization catering to expatriates around the world. The BUPA personal membership guide explicitly states that IVF treatments are not covered.
Cigna is also a nationwide company often subject to mandates. You can read more about how Cigna handles payments and procedures codes in a medical coverage policy document accessible on their website.
Emblem Health is the umbrella corporate name for GHI and HIP health plans serving the New York State region. New York mandate coverage for other infertility treatments. You may easily find coverage for other infertility treatments and medications that may help reduce your out of pocket costs.
Great West Life is a diversified financial services organization operating in Canada. They are not subject to U.S. laws.
Kaiser Permanente is a California based company serving the Golden State. California has a mandate requiring health insurers to offer a plan covering other infertility treatments.
Medicaid is a government run program for indigent populations. You must meet income and asset means testing to qualify. Medicaid does not cover any infertility treatments. State mandates do not apply to government programs. For example, the Illinois mandate does not apply to Medicaid.
Medicare is a federal government program designed primarily for people over the age of 65. This demographic is well past childbearing age.
Ontario Health Insurance Plan (OHIP) is a publicly funded healthcare system in Canada, and not subject to U.S.A. regulations. OHIP may pay benefits for up to three IVF cycles when the treatment is needed because of complete bilateral anatomical fallopian tube blockage.
Tricare is a health care program providing for uniformed service members, retirees, and their families. Other assisted reproductive services may be available for all members, while IVF may be covered for service members wounded while on active duty.
United Health Care is a health services company national in scope. United Health Care is often subject to mandates.
Posted July 10, 2014 by Kevin Haney