Health insurance offers patchwork of coverage for infertility treatments

Amy Higgins

The inability to conceive can be exasperating to a couple wanting to start a family. But while frustration is common, it is not an unusual scenario. According to the federal Centers for Disease Control and Prevention, one in every eight couples of child-bearing age is infertile.

So when nature fails to produce the results these couples yearn for, should they throw their arms in the air in defeat or turn to medicine? A May 2006 survey by Mercer Health and Benefits LLC says 70 percent to 80 percent of those provided the necessary care will achieve a successful outcome if they have access to timely and appropriate infertility treatment.

That’s encouraging news. However, just because the technology is available doesn’t mean all couples have the means to obtain treatment, seeing that it can cost big bucks without suitable health insurance coverage.

Health insurance offers patchwork of coverage for infertility treatments
Health insurance offers patchwork of coverage for infertility treatments

Are you covered?

As of 2005, about 20 percent of employers provided coverage for reproductive therapies like in vitro fertilization (IVF), according to Mercer. Mercer’s survey of 931 employers also found that 54 percent of employers with at least 500 employees covered evaluations by reproductive specialists, and 37 percent covered drug therapy. Just 10 percent covered advanced reproductive procedures, such as gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), the survey showed.

Even if your health insurance policy claims it covers infertility treatments, you could be in for a rude awakening if you’re under the impression that you’re covered in all cases. Kaiser Health News reported the following examples of obstacles that couples could face regarding health insurance coverage and infertility treatments:

  • Your policy could cover the initial consultation and tests to diagnose infertility, but it might not cover procedures to help you conceive.
  • Fertility drugs may be included in your coverage, but more expensive procedures like IVF might not be covered.
  • Your health insurance provider might cap the dollar amount it will pay for services.
  • Some states and policies require the spouse’s sperm to be used for IVF procedures, which is a problem for same-sex couples and men with infertility problems.
  • The number of IVF cycles you’re entitled to may be limited. If you require more IVF cycles than your insurance provider allows, you’ll be forced to quit or to pay for treatment on your own.

Coverage laws

Fifteen states have passed laws requiring that insurance companies provide coverage for some level of infertility treatment as a basic health plan benefit, or at least offer such coverage to customers, according to Mercer.

As of January 2010, the states that mandate infertility coverage wee Arkansas, California, Connecticut, Georgia, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Mexico, New York, Ohio, Rhode Island, Texas and West Virginia, according to the Kaiser Family Foundation. Each state has certain exclusions and requirements. For instance, some laws apply only to HMOs, and others exclude certain infertility treatments.

Other options

Those without infertility treatment coverage can expect hefty medical bills if they choose to pay for procedures on their own. According to the Advanced Fertility Center of Chicago, the average cost for a complete IVF cycle in the United States is about $12,000 plus medication.

If you have health insurance coverage but fertility treatment is not included in your policy, try asking your employer to consider adding the coverage. According a Mercer report, 65 percent of the employers surveyed that offered infertility treatment said employee requests were a major reason for covering infertility benefits.

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