Infertility Insurance Coverage by State
There is no question that living with infertility causes great stress and emotional pain. That stress is only increased when you think about how you are going to pay for it all. Fortunately, 15 states in the U.S. have laws that address infertility insurance coverage. Find out if your state is included.
States with infertility insurance coverage
Currently, 15 states have laws requiring insurers to cover the diagnosis and treatment of infertility. Below is a brief summary of infertility insurance coverage by state along with a link to each state’s insurance website 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. Insurers may impose a lifetime maximum of $15,000 coverage.
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. Patients must have a 5-year history of infertility and other exclusions may apply.
Illinois: HMOs and group 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.
Louisiana: Insurers cannot exclude benefits for treatment and diagnosis of infertility as a result of a treatable medical condition. 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.
Maryland: Certain insurers providing maternity benefits must also cover outpatient costs of IVF. Coverage is provided to couples that have a 2-year history of infertility. Certain exclusions apply.
Massachusetts: Medically necessary costs of infertility diagnosis and treatment must be covered by all insurers that also cover pregnancy-related benefits (self-insurers are an exception). Insurers must cover fertility drugs in comparable ways to other prescription medications. 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: In Montana, HMOs are required to cover infertility services as part of their basic healthcare services.
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. Group policy providers are mandated to offer specific diagnosis and treatment services. Fertility drugs must be covered along with other prescription drugs.
Ohio: HMOs must cover medically necessary infertility diagnostic and treatment procedures. No definition of infertility or infertility services is provided. The law does not mandate coverage for IVF, although insurers may offer coverage for IVF treatment.
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 (religious employers and employers who self-insure are exempt). However, 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 including infertility services.
Definitions and exclusions for infertility insurance
While these 15 states may currently have laws that provide for some type of infertility insurance coverage, certain exclusions do apply. For example, state laws may exclude the following:
- Fertility treatments that use donor sperm or donor eggs
- Coverage for certain infertility treatments and infertility diagnoses
- Where you may go for services and how many treatment cycles will be covered
In addition, many states have age limits and lifetime maximum benefits for coverage. A state may also specify what the definition of infertility must be. Religious organizations, employes that self-insure, small businesses and some HMOs may be exempt from providing coverage.
Because each state varies in providing infertility insurance coverage, you must research your insurance plan coverage carefully. Check your state’s laws to see what type of coverage you are entitled to when it comes to infertility diagnosis and treatment.Sources