I’m Ready for IVF: What Will My Health Insurance Pay For?


I’m Ready for IVF: What Will My Health Insurance Pay For?

When you’re ready to start building your family with fertility treatments, covering the cost is one of your major concerns. Your health insurance plays a role in financing fertility treatment, but how much it will cover varies greatly from state to state and policy to policy.

Most patients don’t know the specifics about their insurance policies. Here are some facts to help you investigate what your health insurance can do for you.

The Affordable Care Act: Good News and Bad News

The passage of the Affordable Care Act (ACA,) sometimes called Obamacare, mandates that health insurance companies provide the same set of essential health benefits, including outpatient care, hospitalization, emergency services, prescription drugs, maternity and newborn care, preventive and wellness services and pediatric services. They can also provide additional health benefits if the plan chooses.

The bad news first: Infertility treatment is not one of the essential health benefits mandated by the ACA. If your health insurance did not cover fertility treatments before, it does not have to now. Now for the good news. Infertility is considered a pre-existing condition. Before the ACA, you could have been denied insurance coverage completely because you had a pre-existing condition. As of 2014, an insurance company cannot refuse to cover you because you are diagnosed as infertile.

State Mandates

According to RESOLVE, the National Fertility Association, 15 states mandate at least some coverage of fertility treatment. Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia each require some coverage, but they do not all require the same coverage. RESOLVE has a good summary of mandated coverage on their website. Get familiar with what your state requires.
If your state does not mandate coverage, some of your diagnosis and treatment may still be covered by your insurance policy. Your insurance carrier and your employer determine the level of coverage your policy offers.

Looking at Your Policy

Health insurance policies fall into one of these five groups:

  • No fertility insurance coverage.
  • Insurance Coverage for Infertility Diagnosis Only.
  • Insurance Coverage for Infertility Diagnosis and Limited Treatment.
  • Full Infertility Insurance Coverage.
  • Medication Coverage (which may or may not include fertility drugs).

If your policy covers infertility diagnosis, a good question to ask your reproductive endocrinologist is, “Will this test or procedure help determine whether or not I have fertility issues and what the cause of the infertility is?” The answer will help you know which expenses will be out-of-pocket and which will be covered. If your plan covers diagnosis and some infertility treatment, check with your individual plan to see exactly what that means. Ask about oral ovulation drugs, injectable fertility drugs, and intrauterine insemination (IUI.)

If you have a male partner, check your partner’s insurance to see if he is covered for his testing and treatment for male factor infertility, if treatment should be necessary for him. If you are a same-sex couple, be sure and find out what coverage each of your policies provides and whether you have coverage for domestic partners or same-sex spouses. This kind of coverage varies by state and by policy.

If your insurance policy provides full infertility coverage, you are lucky! However, be sure and read the fine print and talk to your fertility doctor if egg freezing, preimplantation genetic diagnosis (PGD) or intracellular sperm injection (ICSI) are recommended, so you know in advance if your insurance covers those procedures.

In all cases where there is at least some coverage, be sure to talk to your doctor and the fertility center financial specialist about what your plan will cover. Often a plan will pay for one preferred drug and will not pay for a different one. The same thing goes for labs—make sure you are sent to an in-network lab for your testing.

Fertility drugs are an especially confusing issue. Even if your state has some mandated insurance coverage for fertility treatment, it may not require coverage of fertility medications, or it may cover clomiphene citrate (Clomid) but not the injectable fertility drugs. Even if your insurance does not provide any coverage for fertility treatment, don’t despair. There are financing plans available to help you cover the cost and get the baby you want.

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