Does your insurance cover fertility treatments?

A growing number of states require health insurance to cover infertility treatment, but there are still many gaps.

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Myles Ma, CPFCSenior ReporterMyles Ma, CPFC, is a certified personal finance counselor and former senior reporter at Policygenius, where he covered insurance and personal finance. His expertise has been featured in The Washington Post, PBS, CNBC, CBS News, USA Today, HuffPost, Salon, Inc. Magazine, MarketWatch, and elsewhere.

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Infertility affects about 15% of all couples in the United States. But according to the American Society for Reproductive Medicine, only 24% of infertile couples are able to access the care they need to become pregnant. One major reason is cost. A cycle of in vitro fertilization, one of the most common and effective treatments for infertility, can cost more than $12,000 according to ASRM, and by some accounts, the average cost of a successful birth from IVF is $60,000. And for most people, health insurance won’t pay for IVF or other fertility treatment.

“Insurance companies in the U.S. have historically viewed infertility care as ‘elective’ and have not covered the tests and treatment necessary to diagnose and manage infertility,” says Dr. Ben Peipert, an OB-GYN resident at Duke University School of Medicine.

Peipert is co-author of a study reviewing the impact of state requirements for insurance companies to cover infertility treatment. Twenty states have laws requiring insurers to cover the diagnosis and treatment of infertility, and 14 of those mandate coverage for IVF. These laws vary widely and have a diverse set of exceptions. Many exclude non-traditional or LGBTQ couples. For example, in Arkansas, Hawaii, and Texas, coverage is only required if a patient’s eggs are fertilized with their husband’s sperm. Eight states require you to demonstrate infertility for longer than the medical definition (one year of unprotected sex without conception) to qualify for coverage. 

Still, the overall trend is toward more coverage, Peipert says.

“State-mandated insurance coverage for infertility has expanded and become more comprehensive in recent years,” he says. “We’ve also seen several employer-sponsored plans enter the market which expand access to infertility care among some employees working for organizations offering these plans.”

Here are a few tips to help you pay for infertility treatment.

Find out whether your insurance covers infertility treatment

Your health insurance plan should come with a summary of benefits. You can contact your insurance company or your plan administrator — someone in human resources if you get your insurance through work — can help you get a copy. This summary outlines what the plan covers, what your rights are, and what costs you’ll bear. Look for mentions of infertility to see whether it’s included or excluded from coverage.

Find out whether your state requires coverage for infertility treatment

You can get updated information from the website of the National Infertility Association. Remember: A mandate doesn’t mean you’re in the clear. There are a wide variety of exceptions and requirements that can add hurdles to getting treatment covered, even in states that require coverage.

“The U.S. health care system is inherently fragmented and complex,” Peipert says. “Even in states with state-mandated infertility coverage, millions of people may lack coverage for fertility treatments because they work for a small employer, a federal employer, or a self-insured employer, all of which are exempt from state regulations.”

What to do if you can’t get infertility treatment covered

If you live in a state that doesn’t require coverage and your insurance company doesn’t cover treatment, getting help paying for infertility treatment becomes a matter of negotiation.

“Speak with your doctor to see if there are ways to decrease the cost of treatment or learn about possible payment plans,” Peipert says.

Speak to your employer about whether coverage for infertility treatment can be added to the company’s insurance plan. If you’re denied a claim for coverage for a specific treatment, your insurance company must have a formal process for you to appeal its decision. You can also challenge denials through your state insurance department. 

It may make sense to take infertility treatment into account while job hunting.

“When looking for jobs, inquire about health insurance benefits to see if it will cover treatments such as (intrauterine insemination) and IVF, and if so, how much,” Peipert says.

Finally, there are non-profit organizations who support families who can’t afford infertility treatments. You can find a list of these awarding organizations on the National Infertility Association website.

Peipert hopes there will one day be a federal mandate providing coverage for the diagnosis and treatment of infertility, regardless of state residence or insurance type. His study finds that state mandates for infertility coverage, particularly those requiring comprehensive IVF coverage, lead to improvements in access to infertility treatment and better health outcomes. 

“It’s hard to imagine something like comprehensive infertility coverage passing Congress in today’s political environment, but I haven’t lost hope yet,” Peipert says.

Image: Ridofranz / Getty