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. Infertility is defined as being the inability of a woman to become pregnant after trying for 12 months if under the age of 35, or trying for six months if over age 35, according to the Centers for Disease Control and Prevention (CDC).
The causes of infertility are numerous. 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.
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.
As part of New York’s 2020 budget, a new fertility insurance law 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 72,913 babies were born in the U.S. in 2015 because of ART.
Knowing your options
Prior to 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.
Your study should include 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.
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.
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 or ARC, firms that offer loans specifically for infertility treatments.
Health Savings Accounts (HSAs), which are available through some employers, could also be helpful. You may consult a personal financial adviser as well.