Understanding and navigating the world of insurance and infertility can be tricky (we know, we wrote about it!). What your insurance will cover depends on your insurance, so that might be nothing, just diagnostic testing (to figure out the cause of the infertility), or your entire procedure.
If you live in one of 17 US states that mandate infertility insurance coverage, or one of the seven that has fertility preservation laws, you could have more options.
In this post, you'll find out:
- Which 17 states mandate infertility coverage
- What fertility preservation laws are (and which states offer them)
- How you can find out what your insurance covers
Before we get to the states themselves, an important note: While these states require insurance companies to make coverage available, keep in mind:
- Coverage isn't free. You're still responsible for co-pays even if you have private insurance.
- Coverage is only available once you've proved that you meet the criteria for infertility. You have to get a doctor’s note that shows that you've been unable to conceive after trying via timed, unprotected sex for 12 months if you’re under 35 and six months if you’re over 35; or if you've been unable to carry a pregnancy resulting in a live birth after a year.
- Some states require that people have to experience infertility for up to five (!!) years. If you live in one of the states with these time restraints, make sure to investigate the nuances of the plan.
The state of the states
Here's a look at what these 17 states cover:
1. Arkansas: Covers in-vitro fertilization (IVF) up to $15,000. Both the patient and spouse must have a minimum of two years of unexplained infertility or infertility associated with endometriosis; blocked or surgically removed fallopian tubes that are not the result of voluntary sterilization; or abnormal male factors contributing to the infertility.
2. California: Group insurers must offer coverage of infertility treatment, except for IVF, but employers can decide if they want to make IVF part of their employee benefit package. If they do, they can offer coverage of diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT). (Religious organizations can opt out of coverage.)
3. Connecticut: You must maintain a policy for at least 12 months to be eligible for coverage. Insurance will cover a maximum of four cycles of ovulation induction, three cycles of intrauterine insemination (IUI), two cycles of IVF, GIFT, ZIFT or low tubal ovum transfer, with no more than two embryo implantations per cycle.
4. Delaware: Delaware requires that infertility treatment be covered to the same degree as pregnancy-related benefits. Covered treatments include consultation and diagnostic testing, IUI, fresh and frozen embryo transfers, six completed egg retrievals, IVF (including IVF that uses donor eggs, sperm, and embryos), intra-cytoplasmic sperm injection (ICSI), medications, storage, and more.
5. Hawaii: Both individual and group insurers must cover one cycle of IVF, in which the patient's eggs are fertilized with her spouse's sperm, if either the patient or the patient's spouse has at least five years of infertility, and they've been unable to get pregnant via other treatments that are covered by insurance.
6. Illinois: Both group insurers and HMOs must provide infertility treatment coverage of IVF, uterine embryo lavage, embryo transfer, artificial insemination, GIFT, ZIFT, low tubal ovum transfer, and more — but coverage of IVF, GIFT, and ZIFT is only provided if other less costly treatments haven’t been successful. Up to six egg retrievals are also covered.
7. Louisiana: This is one of the weaker state laws. It states that insurance companies cannot decline coverage for treatable medical conditions that result in infertility solely due to the infertility diagnosis. But it also explains that insurers don’t have to cover fertility drugs, IVF or other assisted reproductive techniques (ART), reversal of tubal ligation, vasectomies, or any other method of sterilization.
8. Maryland: Both individual and group insurance must cover the cost of three IVFs per live birth, with a lifetime maximum cost of $100,000. The patient and spouse must have a two-year history of infertility and have been unable to conceive via less costly treatments.
9. Massachusetts: All insurers must provide coverage for the diagnosis and treatment of infertility, including artificial insemination; IVF; GIFT; sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or inseminated eggs; and more.
10. Montana: HMOs are required to cover infertility services as part of basic healthcare services.
11. New Hampshire: Insurers must provide coverage for evaluations, laboratory assessments, medications, and treatments associated with donor eggs, sperm, and embryos.
12. New Jersey: In order to be eligible for coverage, you must be under age 46 and have been unable to get pregnant via any less costly infertility treatments that are covered by insurance. Coverage includes diagnosis and diagnostic testing, fresh and frozen embryo transfers, IVF, medications, surgery, and more.
13. New York: Group policies must provide coverage for diagnostic tests and procedures such as semen analysis, blood tests, ultrasounds, and up to three IVF cycles (either fresh or frozen embryo transfer).
14. Ohio: HMOs are required to cover infertility treatments when they're deemed "medically necessary." This includes diagnostic procedures. IVF, GIFT, and ZIFT are not required to be covered.
15. Rhode Island: Coverage is provided to women between the ages of 25 and 42 for diagnosis and treatment of infertility, but this doesn't apply to fertility preservation. There is a $100,000 cap on treatment.
16. Texas: Group insurers are required to offer coverage for IVF, but individual employers can decide if they're going to include infertility coverage in their benefit packages. The patient's eggs must be fertilized by their spouse's sperm, and the patient must have at least a five-year history of infertility.
17. West Virginia: HMOs must cover infertility services under “basic healthcare services.”
According to RESOLVE: The National Infertility Association, if you live or work in one of these 17 states, you should find out the following:
- Is your plan fully insured or self-insured? In a fully insured plan, the company pays a premium to the insurance carrier. That premium is fixed for a year, based on the number of employees enrolled each month. In a self-insured plan, the employer provides benefits using the company's funds. A fully insured plan is required to follow state law, but self-insured plans can opt out.
- Does your plan have a "greater than 25" (or greater than 50, etc) policy? If an employer has below a certain number of employees, they may not be required to provide coverage.
- Was your employer's plan written in the state with the infertility law? In general, in order for the law to be honored, it must have been written in the state with the law in place.
States + medically induced infertility insurance
As we mentioned at the top, there are also seven states that require insurance companies to cover treatment for iatrogenic, or medically induced, infertility. Medically induced infertility is infertility that occurs directly or indirectly as a result of a surgery or medication — such as chemotherapy, radiation, or surgery — that compromises the ability to conceive.
Connecticut, Delaware, Rhode Island, New York, New Hampshire, Maryland, and Illinois all currently provide insurance coverage for expenses associated with fertility preservation due to medically induced infertility. Depending on the state, this might include:
- Embryo cryopreservation: Harvesting eggs before you begin treatment, then fertilizing and freezing them for later use.
- Egg freezing (oocyte cryopreservation): Collecting and freezing unfertilized eggs.
- Sperm cryopreservation: Freezing and storing sperm.
Talk with your employer and your HR department about what your plan offers and what could potentially be covered. If you feel comfortable, tell them what your ideal plan would cover in terms of infertility treatment. Making your desires known can empower others (you never know what people are dealing with!), and potentially influence your employer to make different decisions about what they'll include in future plans.
And remember: Modern Fertility's hormone test can help you stay on top of what your hormones are up to so that you can gather the information you need to plan for the future.