Health Insurance and Infertility: A Look at What's Covered and What's Not

Over one-tenth of American women know what it’s like to struggle with infertility, according to research done by the Centers for Disease Control (CDC). Worries about financial stability during fertility treatments can add even more stress when you’re trying to conceive. Thousands of couples have gotten pregnant using fertility treatments, but that help comes at a cost. It’s not always easy to figure out if your health insurance will help you pay for your infertility tests and treatments. Insurance companies that do offer infertility coverage often have lifetime caps on how much they will contribute or which types of procedures they’ll help you pay for. Will your infertility treatments be covered by your insurance? Below, you’ll learn how to find out how to get the most out of the health insurance coverage that you have and what your options are if you aren’t covered.


Can your infertility treatments be covered by insurance?

Insurance coverage for fertility treatments can vary greatly depending on your insurance provider, your employer, and even the state that you live in. Some plans cover a range of treatments, some only cover diagnostic tests, and some may exclude infertility treatments entirely. It all depends on whether your provider considers infertility services “medically necessary.”

When the Affordable Care Act was passed, it increased the accessibility of health insurance for millions of Americans. The ACA prevents health insurance companies from denying coverage or charging higher premiums to people with pre-existing conditions, including infertility. Unfortunately, while the act made it easier for people struggling with infertility to get health insurance, it didn’t require insurance companies to cover fertility services.

Some state governments have stepped up over the past few decades to help their citizens with the high prices of infertility treatments. So far, 15 states—Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia—have passed laws requiring health insurance to at least offer coverage for infertility treatments. Out of those 15 states, all but California and Texas actually require insurance companies to cover infertility treatments. The laws vary from state to state, so it’s important to check the specific guidelines for the state in which you live.

Unfortunately, health insurance companies based in states without infertility coverage laws usually don’t offer much assistance with payment for fertility services.


Which fertility treatments can be covered by insurance?

There are a variety of fertility treatment options, including hormone therapy, insemination techniques, and assisted reproductive technology. The type of treatment that you choose depends on your physician’s recommendations and your specific situation, but it may also depend on what you can afford.

Many health insurance companies will pay for diagnostic tests related to infertility or its underlying causes. Unfortunately, once a diagnosis has been made, most insurance companies will stop paying for medical services related to infertility. In some cases, insurance companies may cover diagnostic procedures performed by a gynecologist, but not by a reproductive endocrinologist, or fertility doctor.

Other infertility treatments, such as intrauterine insemination, in vitro fertilization, and certain reproductive surgeries are less likely to be covered. The costs of these services can vary greatly and it’s important to check with your health insurance provider before any procedure. Even in states that require insurance companies to cover fertility services, most companies have lifetime caps for how much they will cover. For example, some insurance companies cover up to four rounds of IVF, but some may only cover the first $15,000. Other companies exclude IVF from coverage completely.

Other than IVF, some common exclusions may be egg freezing, preimplantation genetic diagnosis, and intracytoplasmic sperm injections. Talk with your physician and your insurance company to know in advance whether these procedures will be covered.

If your insurance policy excludes infertility treatment services completely, a low-cost fertility assistance device such as Stork OTC can be a great option to consider. Cervical cap insemination devices like Stork OTC have pregnancy success rates comparable to intrauterine insemination at a small fraction of the price.

Some health insurance companies may exclude infertility medications from their coverage. These medications can be a big part of the cost of any fertility treatment, so make sure to check your policy’s prescription coverage before talking with your doctor about your treatment options.


How do you know if your fertility treatments are covered?

Health insurance policies can be difficult to understand and specific coverages can often be hard to find. Your insurance policy will fall into one of four categories: full infertility treatment coverage, coverage for diagnosis and limited infertility treatment, coverage for infertility diagnosis only, or no fertility coverage at all. To find out which group you belong to, there are a few ways that you can search through your policy and get a better understanding of what is covered.

If you can access your policy online, use the search function on your computer (Ctrl + F for Windows and Command + F for Mac) to find the terms relevant to infertility treatments. Some useful words to search for are fertility, infertility, in vitro fertilization, assisted reproduction, IVF, and ART. Read all of the sections containing those terms for a fuller understanding of which, if any, fertility services are covered by your health insurance policy.

If you can’t view your policy online, or you have additional questions after reading your policy, you can always call your insurance company and ask about which treatments can be covered. Make sure to ask about any specific infertility coverages or exclusions in your policy. These may include oral ovulation medications, injectable fertility medicines, intrauterine insemination, and in vitro fertilization. Take notes during all phone calls with your insurance company, including the date, time, and the name of the person that you talked to. These are useful for your records and can potentially help you if your insurance denies coverage at a later date.

If you have a male partner, it’s important to also check his insurance for male-factor infertility treatment coverage. Many state infertility insurance laws may exclude male-factor infertility testing and treatment.

Before you begin any treatment plan, you can ask your insurance company for a letter of predetermination of benefits. This allows any coverage limitations to be addressed before the treatments are provided.

If your health insurance company refuses to pay for procedures that you believe should have been covered, it doesn’t mean that you automatically have to pay for those treatments. You have the right to appeal the insurance company’s decision to deny coverage. If you can’t reach an agreement with your insurance, you can also have the case reviewed by an independent third party.


How should you talk to your doctor about financial concerns regarding fertility treatments?

Fertility doctors understand that their services are expensive and not all patients will be able to afford the treatments that they recommend. Many infertility clinics have at least one person on staff that will be able to help you understand how your doctor’s treatment recommendations fit in with your insurance policy coverages.

When you’re discussing your fertility treatment plan with your physician, let them know what is covered by your insurance and what you will have to pay out-of-pocket. This can be especially important when it comes to billing codes for testing and treatment of underlying conditions that affect fertility. Sometimes “diagnostic” procedures will be covered, but “infertility” treatments will not. Your doctor has some flexibility in how they code procedures for billing. Talking to them before they create the bill can save you money on your infertility procedures.

Another way to work with your doctor to save money is to make sure that the drugs that they prescribe are covered by your plan. You should also talk to them about the medical labs that you use for any diagnostic tests. Labs in your insurance network will typically cost less than labs that are out-of-network.


When should you look outside of insurance for financial assistance?

The high prices of infertility treatments can be a huge obstacle for couples trying to conceive. Nobody likes the idea of having to put off fertility services due to cost, but there are options out there to consider before taking a step back from your journey to conceive.

Some IVF clinics offer refund programs, discounts, and financing to help make their services more affordable. In IVF refund programs, you pay a set fee that will be partially refunded if you do not get pregnant after a certain number of IVF cycles. When considering a refund program, you should clarify beforehand what the clinic considers a successful cycle, as well as the clinic’s overall success rates.

There are also a number of infertility financing programs, grants, and scholarships, that you should explore before you decide that you can’t afford to try, or continue trying, to conceive.

The financial struggles that accompany infertility can often be one of the most stressful and limiting parts of the journey. Not all insurance providers are on board with covering even a part of the treatment cost, but that doesn’t mean that you have to stop trying to conceive. Inexpensive treatment options and financial assistance programs can be an important resource for couples struggling with the high cost of infertility treatments. Open communication with your doctor, insurance company, and any outside source of financial assistance will help you create a fertility treatment plan that won’t break the bank.


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