Fertility challenges can be a rude awakening for most couples. They never imagined they would struggle with something that seems to come so easily to others. Once a woman realizes that she or her partner may have a problem, the second big surprise hits—health insurance may not cover fertility treatments or not cover them fully.
If you are struggling with fertility, you are not alone—1 in 5 couples in the US will have trouble conceiving. Time is not on your side when you’re struggling to get pregnant. If you are under 35 and have been trying for a year, it is time to see a fertility specialist. If you are 35 or over, see a fertility specialist after 6 months of trying.
Once you realize that having a baby is not going to be as easy as you had hoped, it is time to get educated about what your health insurance will and will not cover.
Understanding insurance coverage for fertility
Unfortunately, there is no such thing as a standard health insurance policy or standard insurance coverage for fertility treatment. You need to know the specifics about your policy.
Most health insurance policies cover fertility in one of the following ways:
- No insurance coverage: While some insurance policies do not cover fertility treatment, most health insurance policies will at least cover diagnosis and treatment of underlying conditions that may cause infertility, such as polycystic ovary syndrome (PCOS), endometriosis, fibroids, and certain conditions for men, such as low sperm count and endocrine issues.
- Insurance coverage for infertility diagnosis only: These policies cover the cost of diagnosing the cause of infertility. They may cover surgeries necessary to diagnose the cause and may specify what type of healthcare provider can perform these tests and surgeries.
- Insurance coverage for infertility diagnosis and limited treatment: These insurance benefits cover diagnosing the cause of infertility and limited treatment options such as oral medications.
- Full infertility insurance coverage: Wonderful, but rare outside of states that require insurance companies to offer fertility insurance coverage, although self-insured companies are beginning to include fertility treatments in their benefits package. There may be either a limit on the number of in vitro fertilization (IVF) cycles that are covered or a lifetime dollar limit to be used for fertility treatment. These policies may not cover some enhanced procedures, such as embryonic genetic testing or intracytoplasmic sperm injection (ICSI). They also may not cover all the cost of medication needed for treatment.
State mandates for insurance coverage for infertility
Currently, there are 20 states with legislation requiring insurance coverage for infertility treatments. The specifics of exactly what these laws require vary greatly, but they can be grouped generally into 2 categories: mandate to cover and mandate to offer.
In practice, the picture is more complicated even if you live in a state that mandates some type of insurance coverage for infertility. The following situations may be excluded from this mandate:
- Self-insured plans, which include many larger companies, may be exempt from state law.
- Employers with fewer than a specific number of employees do not have to provide health insurance at all, so small businesses, startups, and many nonprofits may not offer insurance, and employees will have to find their own policy.
- Some states, such as California, do not require religious organizations to offer coverage for fertility treatments.
And just because your state has a mandate for insurance to cover fertility, these mandates vary significantly as to what and how much they cover.
Pay attention to your drug coverage
Fertility treatment requires specialized medication, so it is important to pay particular attention to how your health insurance policy handles medication.
The important point is for you and your doctor to know this in advance of treatment to develop a treatment plan that will maximize your chance for a baby while minimizing your out-of-pocket expenses.
Who can help you understand your insurance coverage?
Fertility insurance coverage can be very confusing, and even if you have read your full policy (and most of us have not), you will likely have questions. Where do you go to get answers on your possible insurance coverage for fertility treatment?
The first place to go is the Human Resources (HR) department where you work. Ask who can explain your health insurance policy and how it handles the diagnoses and treatment of fertility challenges. Also ask them if telehealth visits are covered under your insurance. Have them explain your coverage, but also ask for a full copy of your insurance policy.
Ask your HR department for a link to where you can find your policy online because it is a lot easier to find the relevant coverage using the online search function to find the words “fertility” and “infertility” than it is to skim a printed copy for these words.
You may also want to call your health insurance company and ask to speak with someone in Member Services. The phone number is usually on the back of your insurance card. Take notes and include the date and name of the person with whom you spoke.
Last, but not least, most fertility clinics have someone on staff who works with insurance, and these folks are often a great source for understanding your insurance coverage.
It is your responsibility to understand your insurance coverage for fertility, but there are resources to help. Also, keep in mind that even if you do not have the best insurance, you have other options for affording treatment. Ask your clinic about plans they might have to help reduce the cost.