There’s no question that living with infertility causes great stress and emotional pain. However, there’s another enormous hurdle to overcome. Infertility treatment is expensive — and someone has to foot the bill. Fortunately, there is mandated infertility insurance coverage by state for fourteen states in the U.S.
Infertility and insurance coverage
If you are fortunate, then you live in a location where there is infertility insurance coverage by state. Unfortunately, a lot of these states have stipulations for coverage. For example, the laws may dictate the following:
- coverage cannot be used if you use donor sperm or eggs
- coverage can only be used for certain types of infertility treatments
- coverage can dictate who performs the treatment and where it’s performed
- coverage can dictate how many cycles will be covered.
In addition, infertility insurance coverage for states may have age limits, as well as a cap on the amount that can be covered.
Many states also offer a “definition of infertility” that you must fit in order to have coverage. Religious organizations, self-insured plans, small businesses with few employees, as well as HMOs are often exempt from having to cover these treatments, unless noted otherwise.
Infertility insurance coverage by state
Currently, 14 states have laws requiring insurers to cover the diagnosis and treatment of infertility. Below is a summary of infertility insurance coverage by state along with a link to the state’s site for more information.
Arkansas: All health insurers (except HMOs) that cover maternity benefits must cover IVF. Infertility treatment benefits are subject to the same deductibles and co-pays as maternity benefits
California: The law only requires insurers to inform employers that this coverage is available. Insurers are not required to provide the coverage and employers are able to choose if they will provide it in their employee benefits package. The types of benefits included are, but not limited to, diagnosis and diagnostic testing, medication, surgery and GIFT. Insurers are specifically exempt from having to provide coverage for IVF.
Connecticut: Individual and group health insurers are required to cover infertility diagnosis and treatment expenses when medically necessary for individuals under 40 years old.
Hawaii: Individual and group health insurers who provide pregnancy-related benefits must also provide a one-time only benefit for outpatient costs from IVF.
Illinois: Insurers covering more than 25 people and providing maternity benefits must also provide benefits for the cost and treatment of infertility. Infertility is defined as the inability to get pregnant after one year of unprotected sex or the inability to carry a pregnancy to term.
Maryland: Certain insurers providing maternity benefits must also cover outpatient costs of IVF.
Massachusetts: Medically necessary costs of infertility diagnosis and treatment must be covered by HMOs and those insurers that also cover pregnancy-related benefits. Infertility is defined as “the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period.”
Montana: HMOs are required to cover infertility services as part of their basic preventive healthcare services. However, infertility and the scope of infertility services are not defined by the law. Besides HMOs, infertility services are specifically excluded from the scope of health benefits other insurers must provide
New Jersey: Insurers that provide pregnancy-related benefits must also provide benefits to cover the cost of the diagnosis and treatment of infertility. Infertility is defined as “the disease or condition that results in the inability to carry a pregnancy to term or the inability to get pregnant after two years of unprotected sex for a female partner under the age of 35 or one year of unprotected sex for a female partner over the age of 35.”
New York: Private and group health insurers are prohibited from excluding coverage of hospital, medical or surgical care for the diagnosis and treatment of a correctable medical condition solely because the condition results in infertility
Ohio: HMOs must cover basic preventive health services, including fertility, when medically necessary. No definition of infertility or infertility services is provided.
Rhode Island: Insurers and HMOs covering the costs of pregnancy services must also cover the costs of the diagnosis and treatment of infertility when medically necessary. Infertility is defined as “the condition of an otherwise health married individual who is unable to conceive or produce conception during a period of one year.”
Texas: Group insurers who cover pregnancy services are required to offer coverage for IVF. Employers may choose whether or not to include infertility coverage as part of their employee insurance plans.
West Virginia: HMOs are required to cover basic health care services when medically necessary. These services include infertility services.
One state, Louisiana, passed a law prohibiting the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility. However, the law does not require insurers to cover fertility drugs, IVF or other assisted reproductive techniques, or reversal of tubal ligation, vasectomy or any other form of sterilization.
In doing your research about infertility insurance coverage by state, be sure to check your state’s statutes as well as with your employer to see what type of coverage you are entitled to for infertility diagnosis and treatment.
Sources: Resolve.org: The National Infertility Association: State Info on Insurance Coverage. American Society of Reproductive Medicine: State Infertility Insurance Laws.
