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What to know about insurance and infertility

couple reviewing their health insurance for fertility benefits

If you are planning to seek infertility treatment, you are no doubt concerned about affording treatment. Many couples handle the cost by themselves because their health insurance does not cover infertility treatment. However, New York is one of 15 states that has an infertility insurance mandate in place. An infertility insurance mandate is a law that requires insurance companies to cover, or to offer coverage, for infertility.

Overview of the state of infertility in the US

According to the National Institutes of Health (NIH), 9 percent of males and 11 percent of females have trouble conceiving. The Centers for Disease Control and Prevention (CDC) has defined Infertility as the inability of a woman to become pregnant after trying for 12 months if she’s under the age of 35. If a woman is over the age of 35, then she would only need to try for six months.

There are numerous causes of infertility. In one-third of the cases it is caused by male factor, in one-third it is caused by female factor, and in one-third it is a combination of both or undetermined, according to the NIH. Medical expenses may be incurred for hospital, surgical and medical care, as well as diagnostic tests such as semen analysis, blood tests and ultrasound.

At Genesis, we want to be as transparent as possible in communicating how the Supreme Court decision to overturn Roe v. Wade may affect our patients’ care.  Be assured we remain vigilant in providing the highest quality care to our patients. For the most current information see Resolve: The National Infertility Association’s “Understanding IVF Access in a Post Roe v Wade World”.

Fertility and insurance

States like New York mandate that health insurance policies cannot prohibit coverage for medical conditions just because they result in infertility. The Affordable Care Act (ACA or Obamacare) provided no mandate for infertility treatment.

In 2020, New York instituted a new fertility insurance law which mandates some insurance plans to cover in vitro fertilization (IVF), which is the most common and effective form of Assisted Reproductive Technology (ART). IVF and other treatment methods involve manipulating sperm, eggs and embryos outside the body. Also, all private insurance plans must cover medically necessary egg freezing.

According to the CDC, a total 74,590 babies were born in the U.S. in 2018 because of ART. In 2019, 2.1% of all infants born in the United States (includes the 50 states, the District of Columbia, and Puerto Rico) were conceived with the use of ART.

Take the Next Step – Schedule an Appointment

Know your options

Before seeking treatment, you should study your insurance policy to see if infertility treatment is covered, and what specific items are mentioned. Insurance through employers may cover treatment even though a state may not mandate it.

You should know exactly what benefits are covered, and what is excluded or restricted regarding infertility diagnosis and treatment. If you are dealing with your employer’s health plan, you should be able to get a Summary Plan Description (SPD) from your administrator.

insurance and infertility

Also check your dependents’ coverage. Find out what’s covered, what the co-payments are, and the information on pre-existing conditions, if needed. Large employers such as Facebook and Apple have said they will add “fertility preservation treatments” to their health coverage. Other large companies also plan to follow suit.

Employers can add infertility treatment to their plans even though the state does not mandate it, so it never hurts to ask your employer to add the coverage. Some even offer reimbursement for expenses up to a certain dollar amount.

Some plans may cover laboratory work to help diagnose a condition that may lead to infertility; or the treatment itself may be considered medically necessary. If you are seeking IVF, some insurers may require you to have attempted a certain number of unsuccessful artificial insemination procedures before allowing you to proceed to IVF.

If your health insurance is up for renewal and you’re trying to decide which plan to choose, you can compare New York State Health Insurance plans here.

Moving forward with care

Once your diagnosis is established and a treatment plan outlined for your personal situation, you should consult with the billing department to discuss your financial obligations and how to pay them. If you have little or no insurance coverage, loans are available through CapexMD, Future Family or ARC Fertility. These are companies that offer loans specifically for infertility treatments.

GENESIS is now partnered with Embryo Options for all sperm, egg & embryo storage billing. This helps patients budget their billing for storage with convenient monthly or quarterly payment plan options.

Health Savings Accounts (HSAs), which are available through some employers, could also be helpful. You may consult a personal financial adviser as well.

Additional Resources:

Original post 1/24/2019
Most recent update 1/4/2024

If you would like to learn more about GENESIS Fertility New York or are ready to schedule an appointment, please speak with one of our representatives at 718-GENESIS.

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