Health insurance infertility treatment coverage rarely exists, except for when it does. Issuers do not want to pay for the procedures, or the resulting pregnancies, or for multiple births that deliver preterm. Laws in sixteen states make them do so in certain cases.
Narrow the odds of finding what you want by understanding the bad economics for issuing companies, the legal environment, and how the two may apply to providers in your local area.
- Why healthcare plans rarely cover infertility
- How state mandates make them do it anyway
- Where the regulations apply to different providers
Why Insurance Does Not Cover Infertility Treatments
In order to identify which health insurance plans and providers do cover infertility treatments, you need to understand the reasons why they often do not. Many cite that the procedures are not medically necessary, or that they are experimental. However, that is not the main reason. The main reason that insurance does not cover infertility treatments is the bad economics, and impact of multiple births on costs.
Infertility financing programs helps most couples to start their treatments when their existing coverage will not pay. Make sure you secure mom’s income prior to conception.
Bad economics is the first reason why insurance does not cover infertility treatments. Healthy, barren couples do not generate claims. Those able to conceive do.
Any healthcare plan must pay for the cost of the artificial reproductive technologies (ART), medical management of the resulting conception, and hospital labor and delivery charges. As a result, most carriers resist including infertility treatments – doing so makes poor business sense.
Supplemental health insurance has better economics, and is more readily available.
The high incidence of multiple births is the second reason why insurance does not cover infertility treatments. Multiple births amplify the bad economics.
ART dramatically increase the odds of conceiving twins and triplets. Multiple pregnancies are often high-risk and deliver prematurely. The costs of nurturing twins in the Neonatal Intensive Care Unit (NICU) average ten to twenty times the costs for a healthy singleton birth.
Perceptive couples understand that insurers do not want to take on this risk, but state laws decree they do in specific instances. By understanding how these regulations work, who must comply, and where the loopholes are, you may be able to find a policy that pays benefits for your artificial reproductive technologies.
Infertility Insurance Mandate States
There are sixteen different infertility insurance mandate states. The legal requirements apply in the issue jurisdiction of each plan. Most laws apply to group programs, rather than those issued directly to individuals.
If an employer group headquarters in a mandate state, and issues a plan in that jurisdiction, then employees working in other locations must receive the same benefits. Do not overlook this distinction.
Each legal mandate differs from the other in terms of the plan designs included, sizes of groups regulated, and the types of treatments specifically included and excluded. Obamacare sometimes intersects.
State infertility insurance mandates sometimes specifically include or exclude certain treatments in the legal language, and other times exclude them by omission.
- Tubal ligation reversal and vasectomy reversals are always excluded.
- Plans subject to broader requirement often cover fertility drugs and injectable medications.
- In Vitro Fertilization coverage is either specifically excluded or included. Rarely do the laws ignore the topic.
- California recently amended its regulation to extend benefits to gay and lesbian couples. Other states may limit benefits to gay couples through alternate language. For example, one law indicates that the husband’s sperm must impregnate his wife.
- Most cover diagnostics and testing even without a law if an underlying medical condition causes the problem.
The Affordable Care Act (ACA) is the centerpiece of the healthcare reform movement. People frequently refer to the new law as Obamacare. It is a federal regulation that often intersects with state laws.
Obamacare does not directly address health insurance coverage for infertility treatments. However, the new legislation affects what couples may expect to pay in three areas.
- Mandates may apply to more individual and small group plans.
- Couples have better options to cover mom’s resulting pregnancy and hospital delivery.
- Tax deductible medical expense savings were reduced.
You can read a more thorough analysis of the effect of Obamacare on treatment coverage on another page.
Infertility Health Insurance Providers
Many couples begin the process of finding health insurance covering infertility treatments by typing a provider name qualifier. In general, the providers shy away from offering this benefit as already described. Your answer reveals itself in the state mandates section, rather than in the name.
While name may not be the ideal way to frame the question, you may find some answers by scanning the rather long list of providers broken down into public, and private sector providers. Follow the links for more information.
Public Sector Providers
Several public sector providers offer health insurance coverage for infertility treatments. You may be in luck if you already have one of these programs, or you qualify to become a member.
Champ VA – The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered services and supplies with eligible beneficiaries. It includes testing and treatment, including correction of the physical cause.
Federal Employees Health Benefits Program – Offers a variety of plan designs, which cover the diagnosis and treatment including artificial insemination and medications across all states. Expanded benefits are required for plans issued in mandate states.
Tricare – Is a health care program providing for uniformed service members,
retirees, and their families. Tricare covers infertility services that are medically necessary, and combined with natural conception. Service members injured in the line of duty sometimes qualify for additional services.
VA – The Veterans Health Administration is America’s largest integrated health care system with over 1,700 sites of care, serving 8.76 million veterans each year. VA benefits include infertility assessment, counseling, and treatment.
Medicare and Medicaid
Medicare and Medicaid are public programs that do not provide health insurance coverage for infertility treatments. Medicare addresses the needs of adults over the age of 65. This population is well past childbearing age. Medicaid provides basic healthcare support for low-income families.
Many carriers offer Medicaid and Medicare in addition to private plans. Others focus exclusively on this market. In every instance, they use an alternative name. Below is an abbreviated list of the most frequently searched named exclusive carriers.
Arizona Health Care Cost Containment System AHCCS – Operates Medicaid for Arizona residents meeting income guidelines.
Badger Care – Operates Medicaid programs for low-income Wisconsin residents.
Inland Empire Healthcare Plan (IEHP) – Offers Medicare and Medicaid programs in California.
MaineCare – Manages Medicaid programs for residents of Maine.
Molina Healthcare – Provides Medicaid and Medicare in 10 states.
Private Healthcare Companies
Private healthcare companies sometimes cover infertility treatments when required by law. As explained earlier, the state of issue dictates which rules govern. For group plans, you have to identify the origin location of issue in order to determine if a mandate applies.
The private marketplace can be confusing. There are many overlapping brands, companies operating in different geographies, and offering alternative services.
Blue Cross Blue Shield (BCBS)
Blue Cross Blue Shield (BCBS) is a healthcare system consisting of thirty-seven independently owned and operated member companies. Each affiliate uses a unique brand name in conjunction with the BCBS shield or logo. Below is an abbreviated list of the most frequently searched affiliate names.
Anthem Blue Cross – Operates in fourteen different states. Five have legal obligations that may apply.
Carefirst – Is an affiliate company operating in the Washington DC area. Maryland decrees IVF coverage.
Empire Blue Cross – An affiliate operating in New York, which has a regulation applying to groups of two or more employee. Individual plans do not need to comply.
Many tradition carriers offer health insurance coverage for infertility treatments when the policy is issued in a mandate jurisdiction. Many of these carriers operate in multiple states, each with a unique set of requirements. Each carrier may have plans that do, and do not cover.
Below is an abbreviated list of frequently searched traditional carriers.
AvMed Health Plans – Operates primarily in Florida with no requirements.
Amerigroup – Operates in twelve states. Five have decrees that may apply.
Bupa – Is an international healthcare services company. These do not include any assisted reproduction treatment. However, certain “infertility investigations” may be covered after a waiting period.
Coventry Health Care – Operates in twenty-four states. Only four have a requirement.
Cigna – Offers plans in ten states. Three have obligations. Read more about how Cigna covers treatments when compelled.
Emblem Health – Provides individual and family policies in New York, which has a directive. Also does business under the name of GHI.
Health New England – Provides health insurance in Massachusetts, which has comprehensive requirements.
Healthy New York – Provides healthcare plans in New York for individuals, self-employed, and small businesses with less than 50 employees. The NY regulation applies to groups with two or more employees, meaning the small business must cover, but not the other two.
Humana – Offers individual plans in twenty-two states. Individual policies rarely must comply with decrees.
Kaiser Permanente – Operates primarily in California as the leading provider. Must offer something for groups, although employers are not forced to purchase on behalf of employees.
MagnaCare – Offers healthcare solutions for trade unions and self-insured employers in the New York and New Jersey areas. Both NY and NJ have requirements, but exempt self-insured employers.
National Health Services (NHS) – Is a UK based carrier subject to regulations outside the scope of this article.
Neighborhood Health Plan (NHP) – Offers group and individual programs in Massachusetts, which has a requirement. According to their published documents, commercial versions do cover services, while the MassHealth and Commonwealth Care do not.
Network Health – Is now known as Tufts Health Plan and offers three different programs in Massachusetts. The Healthcare Unify (Medicare and Medicaid), and Network Health Choice do not cover services, but Tufts Health Direct does.
Select Health – Offers programs in Utah and Idaho. Documents explicitly exclude infertility.
Many times consumers interface with alternate service organizations, or encounter new legal terms. In general, these entities do not provide health insurance coverage for infertility treatments directly.
Aflac – Provides supplemental programs, which replace lost income during pregnancy.
COBRA – The Consolidated Omnibus Budget Reconciliation Act provides workers the opportunity to continue coverage when separated from employment. Benefits remain the same.
CareCredit – Provides financing and loans for medical procedures.
Discovery Benefits – Provides healthcare administration services.
Medco – Recently merged with Express Scripts. This mail order pharmacy ships many fertility drugs on behalf of partner healthcare companies. The underlying plan dictates what percentage of the medication costs are your share.
UMR – UMR is a third-party administrator (TPA), hired by your employer, to help ensure that your claims are paid correctly. UMR is not an insurance company. Refer to your employer for benefit details. UMR may primarily service self-insured employers that are commonly exempt from mandates.
Posted November 5, 2014 by Kevin Haney