Does Insurance Cover IVF: Guide to Infertility and IVF Insurance Coverage

Due to the high cost of IVF treatment, most suffer not only emotionally but also financially. The infertile pay premiums for health benefits , such as maternity services , that they are unable to use. We believes that infertility and IVF treatment should be covered by health plans. Infertility is a disease and should be treated as such by insurance companies. Currently, no federal legislation exists mandating insurance coverage for infertility and IVF treatment. Only 15 States in US have mandates to provide or offer insurance coverage for infertility and IVF treatment.

Insurance coverage for infertility and IVF treatment

Although no federal law requires insurance coverage for infertility and IVF treatment, 15 states have enacted some type of infertility insurance coverage law.

Laws vary according to each state, but generally can be described as either a mandate to cover or a mandate to offer. A mandate to cover is a law requiring that health insurance companies provide coverage of infertility and IVF treatment as a benefit included in every policy. The policy premium includes the cost of infertility and IVF treatment coverage. A mandate to offer is a law requiring that health insurance companies make available for purchase a policy that offers coverage of infertility and IVF treatment. The law does not require employees to pay for the infertility and IVF treatment coverage.

Since laws change all the time, we recommend you check with your state concerning its current regulations on infertility coverage.

Every insurance policy is different and it is important to thoroughly understand your particular plan, paying specific attention to covered benefits, exclusions and restrictions.

Don’t be taken by surprise when an insurance claim is denied. You can prepare yourself by thoroughly understanding your plan and ensuring that you follow appropriate steps and have accurate information. Coverage of treatment for infertility and IVF varies from plan to plan and state to state. Refer to this guide and to your plan to determine what specifically is covered. If you are uncertain about your coverage or your insurance company is not offering coverage, some states have a department of insurance that can provide information. Check your state’s Web site for contact information.

As you move forward, ask your doctor to check diagnosis and procedure codes for accuracy.

 

Infertility and IVF Insurance Coverage in States

State Infertility and IVF Insurance Coverage at a Glance

StateMandate to coverMandate to offerIncludes IVF coverageExcludes IVF coverageIVF coverage ONLY
ArkansasX(1)X
CaliforniaXX(2)
ConnecticutXX
HawaiiXX(3)
IllinoisXX(4)
LouisianaX
MarylandX(5)X
MassachusettsXX
MontanaX(6)
New JerseyXX
New YorkX(7)
OhioX(8)
Rhode IslandXX
TexasXX
West VirginiaX(8)
  1. Includes a lifetime maximum benefit of not less than $15,000.
  2. Excludes IVF, but covers GIFT.
  3. Provides a one-time only benefit covering all outpatient expenses arising from IVF.
  4. Limits first-time attempts to four oocyte retrievals. If a child is born, two complete oocyte retrievals for a second birth are covered. Businesses with 25 or fewer employees are exempt from having to provide the coverage specified by the law.
  5. Businesses with 50 or fewer employees do not have to provide coverage specified by law.
  6. Applies to HMOs only; other insurers specifically are exempt from having to provide the coverage.
  7. Provides coverage for the “diagnosis and treatment of correctable medial conditions.” Does not consider IVF a corrective treatment.
  8. Applies to HMOs only.

 

ARKANSAS

The state of Arkansas requires that all health insurers that cover maternity benefits must also cover the cost of in vitro fertilization (IVF). HMOs however, are exempt from the law. IVF benefits are subject to the same deductibles and co-insurance payments as maternity benefits. The law also limits coverage to a lifetime maximum of $15,000. Patients must also meet certain conditions as well, so it is important to understand your specific medical situation.

Who is covered?

To be eligible for coverage, you must be the policy-holder or the spouse of the policy-holder and be covered by the policy. Your eggs must be fertilized with your spouse’s sperm. In addition, you and your spouse must have at least a two-year history of unexplained infertility or the infertility must be associated with one or more of the following conditions:

  • Endometriosis
  • Fetal exposure to diethylstilbestrol, also known as DES
  • Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization
  • Abnormal male factors contributing to infertility

You also are eligible for coverage if you have not been able to achieve conception through a less costly treatment that may be available under the policy. The IVF procedure you undergo must also be performed at a medical facility licensed or certified by the Arkansas Department of Health, conforming to the American College of Obstetricians and Gynecologists guidelines for IVF clinics or meet the American Fertility Society’s minimal standards for programs of in vitro fertilization.

Who is not covered?

If neither you nor your spouse is the policy-holder covered by the policy, you are not necessarily eligible. Also, if your eggs are not fertilized with your spouse’s sperm, or if you do not have a two-year history of infertility, you will not be covered. If you have been covered for over

$15,000 worth of IVF practices and/or procedures, you will not be eligible for more coverage in the future.

CALIFORNIA

The State of California requires certain insurers to offer coverage for infertility diagnosis and treatment. However, the law does not require those insurers to provide the coverage, nor does it force employers to include it in their employee insurance plans.

Who is covered?

Assuming your insurance is one that offers this coverage, you are eligible to purchase it. Your treatment would include, but not be limited to diagnosis and diagnostic testing, medication, surgery, and GIFT

(Gamete Intrafallopian Transfer).

Who is not covered?

The law specifically exempts insurers from having to offer IVF coverage, so if it is not included in your insurance plan, you are ineligible. Also, the law does not require employers of religious organizations to offer coverage if it conflicts with the organization’s religious and ethical purposes.

CONNECTICUT

Connecticut requires health insurers to offer coverage for infertility diagnosis and treatment, including IVF. Insurers must let employers know this coverage is available; however, the law does not require those insurers to provide the coverage, nor does it force employers to include it in their employee insurance plans.

Who is covered?

If you are under an insurance plan that offers coverage and if you meet the criteria involved in determining infertility, you are covered. That criterion defines infertility as the condition of a presumably healthy individual who, over the course of a year, is unable to get pregnant or unable to carry a pregnancy to term.

Who is not covered?

If your insurance plan is not required to provide coverage, you will not automatically receive it, but with a “mandate to offer,” you can purchase a policy offering that same coverage. Further, if you are not considered infertile by the state, you may not be eligible.

HAWAII

Hawaii requires certain insurance plans to provide a one-time only benefit for outpatient costs resulting from IVF. Those plans include individual and group health insurance plans, hospital contracts or medical service plan contracts that provide pregnancy-related benefits. Patients also need to meet certain conditions in order to get their IVF covered.

Who is covered?

In order to receive coverage, your eggs must be fertilized with your spouse’s sperm. You must have had at least a five-year history of infertility, and have been unable to get and stay pregnant through other infertility and IVF treatments covered by insurance. Also, in order to receive coverage, your IVF procedures must be performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. Your infertility must be associated with one or more of the following conditions:

  • Endometriosis
  • Fetal exposure to diethylstilbestrol, also known as DES
  • Blocked or surgically removed fallopian tubes
  • Abnormal male factors contributing to the infertility

ILLINOIS

Illinois requires insurance policies that cover more than 25 people and provide pregnancy-related benefits to cover costs of the diagnosis and treatment of infertility. The law defines infertility as the inability to get pregnant after one year of unprotected sex or the inability to carry a pregnancy to term.

Who is covered?

If you are under an insurance policy covering over 25 people and providing pregnancy-related benefits, you are eligible as long as you are deemed “infertile” by the state.

Coverage includes, but is not limited to:

  • In vitro fertilization (IVF)
  • Uterine embryo lavage
  • Embryo transfer
  • Artificial insemination
  • Gamete intrafallopian transfer (GIFT)
  • Zygote intrafallopian transfer (ZIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Four completed egg retrievals per lifetime
  • Low tubal egg transfer

Coverage for IVF, GIFT and ZIFT is required only if:

  • You have used all reasonable, less expensive and medically appropriate treatments and are still unable to get pregnant or carry a pregnancy
  • You have not reached the maximum number of allowed egg retrievals
  • The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists

Who is not covered?

If you are employed by a religious organization, the law exempts those groups that believe the covered procedures violate their teachings and beliefs.

LOUISIANA

The state of Louisiana does not mandate coverage for infertility. However, it does not exclude coverage for a correctable medical condition on the basis of infertility.

Who is covered?

If you are diagnosed with a correctable medical condition, such as endometriosis, which results in infertility, your insurance plan is required to cover the cost of treatment.

Who is not covered?

If your doctor does not diagnose you with a correctable medical condition, your insurance plan is not required to cover fertility drugs, in vitro fertilization, reversal of tubal ligation, a vasectomy, or any other method of sterilization.

MARYLAND

Maryland requires health and hospital insurance policies that provide pregnancy-related benefits to also cover the outpatient costs of IVF. Policies that must provide the coverage include those covering people who live and work in the state, regardless of whether or not the policy is issued inside or outside the state. HMOs must provide IVF benefits to the same extent as the benefits provided for other infertility services.

Who is covered?

In order to have your IVF practices covered, your eggs must be fertilized with your spouse’s sperm. In addition, if you have been unable to get pregnant through less expensive, covered treatments, you are also

eligible. Your IVF must be performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists and you or your spouse must have at least a two-year history of infertility. If not, your infertility must be associated with one or more of the following conditions:

  • Endometriosis
  • Fetal exposure to diethylstilbestrol (DES)
  • Blocked or surgically removed fallopian tubes
  • Abnormal male factors, including oligozoospermia

Your coverage may be limited to three IVF attempts per live birth and a maximum lifetime benefit of $100,000.

Who is not covered?

If you are employed by a religious organization, you may not be eligible. The law exempts those groups that believe the covered procedures violate their teachings and beliefs.

MASSACHUSETTS

Massachusetts requires HMOs and insurance companies that cover pregnancy-related benefits to cover infertility diagnosis and treatment. The law defines infertility as “the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period.”

Who is covered?

If you are under an HMO or insurance company that covers pregnancy benefits, you are eligible as long as you are deemed “infertile” by the state. Benefits covered include:

  • Artificial insemination
  • In vitro fertilization (IVF)
  • Gamete intrafallopian tube transfer (GIFT)
  • Sperm, egg and/or inseminated egg retrieval, to the extent that those costs are not covered by the donor’s insurer
  • Intracytoplasmic sperm injection (ICSI) for the treatment of male infertility
  • Zygote intrafallopian transfer (ZIFT)

Insurers may, but are not required to, cover experimental procedures, surrogacy, and reversal of voluntary sterilization or cryopreservation of eggs.

MONTANA

Montana requires HMOs to cover infertility services as part of basic preventive health care services. The law does not define infertility or the extent to which these services are offered. Other than HMOs, the law excludes infertility coverage from the required scope of health benefits those insurers must provide.

NEW JERSEY

New Jersey, through the Family Building Act, requires insurance policies that cover more than 50 people and provide pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility.

Who is covered?

The State of New Jersey defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex for females under the age of 35 or one year of unprotected sex for females over the age of 35. If you fall into either category, and are under the necessary insurance policy, then you are eligible. Coverage includes, but is not limited to:

  • Diagnosis and diagnostic testing
  • Medications
  • Surgery
  • In vitro fertilization (IVF)
  • Embryo transfer
  • Artificial insemination
  • Gamete intrafallopian transfer (GIFT)
  • Zygote intrafallopian transfer (ZIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Four completed egg retrievals per lifetime

Coverage for IVF, GIFT, and ZIFT is required only if the patient has used all less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy to term, if the patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger, and if the procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

Who is not covered?

If you are employed by a religious organization, the law exempts

those groups that believe the covered procedures violate their teachings and beliefs.

NEW YORK

The State of New York passed a bill, signed on May 29, 2002 stating that it will assist those in need of fertility treatments through mandating insurance coverage. The mandate is effective for policies issued or renewed on or after September 1, 2002 and coverage provides for those previously covered under the policy for at least one year.

Who is covered?

Before you can determine what type of coverage you will receive from the State of New York, you must find out whether or not you are in fact eligible. Although the bill was passed mandating coverage, it only refers to every “group policy” in New York that provides coverage for regular hospital care. If you are under a group policy, then you are insured during the diagnosis and treatment of infertility. The bill also states that you may receive this coverage only if you are between the ages of twenty-one and forty-four.

Assuming you are under a group policy that provides coverage for other types of hospital care, making you eligible for fertility treatments, you will be covered during surgical or medical procedures that would attempt to correct infertility. Coverage also includes diagnostic tests and hospital procedures that help to determine infertility, as well as FDA approved prescription drugs for such diagnosis and treatment.

Who is not covered?

If you are not part of a group policy in New York that provides coverage for hospital care, then you are not necessarily eligible. For example, if you work for a multi-state corporation based outside of New York or your company is self-insured, you are not covered. (This is true of all state mandates). Those companies are bound only by federal mandates, and if you don’t have any insurance or are on Medicaid, then you’re not covered. Also, if you are not between the ages of twenty-one and forty-four years or have not been under the policy for at least one year, then you are not necessarily eligible. Coverage is not required to include the diagnosis and treatment of infertility in connection with:

  • In vitro fertilization (IVF)
  • Gamete intrafallopian tube transfers (GIFT)
  • Zygote intrafallopian tube transfers (ZIFT)
  • The reversal of elective sterilizations
  • Sex change procedures, cloning
  • Experimental medical or surgical services or procedures.

Assistance for those not covered

In order to assist New York residents with insurance plans that do not cover in vitro fertilization and gamete intrafallopian tube transfers, a $10 million grant has been issued to cover a percentage of some costs. The New York Commissioner of Health has established this program to provide grants to health care providers for the purpose of improving access to infertility services, treatments, and procedures for all in need. The grant assistance will be through a limited number of fertility clinics across the state. Co-payment for treatments is based on household income, but a broad range of incomes is included. Ask your provider if his/her clinic has agreed to the use of this grant for its patients and if you qualify.

OHIO

Ohio’s law requires HMOs to cover basic preventive health services, including infertility. The Ohio Department of Health has no written definition of infertility services, but states that the procedure must be medically necessary. Experimental procedures are not covered.

RHODE ISLAND

Rhode Island requires insurers and HMOs that cover pregnancy services to cover the cost of medically necessary expenses of diagnosis and treatment of infertility. The law defines infertility as “the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year.” The patient’s co-payment cannot exceed 20%.

Who is covered?

If your HMO or insurance company covers pregnancy costs, you are eligible as long as you meet the definition of being “infertile.”

TEXAS

Texas requires certain insurers that cover pregnancy services to offer coverage for IVF. However, the law does not state that they must provide the coverage, nor does it force employers to include it in their health plans. Patients need to meet certain conditions to get their IVF covered.

Who is covered?

If you are under a health plan covering pregnancy services and are offered IVF coverage, you may choose to purchase it. You also are eligible if you meet the following conditions:

  • You must be the policyholder or the spouse of the policyholder and be covered by the policy
  • Your eggs must be fertilized with your spouse’s sperm
  • You have been unable to get and stay pregnant through other infertility and IVF treatments covered by insurance
  • The IVF treatment is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists
  • You and your spouse must have had at least a continuous five-year history of unexplained infertility, or the infertility must be associated with one or more of the following conditions:
  • Endometriosis
  • Fetal exposure to diethylstilbestrol (DES)
  • Blocked or surgical removal of one or both fallopian tubes
  • Oligospermia

Who is not covered?

If you are employed by a religious organization, the law exempts those groups that believe the covered procedures violate their teachings and beliefs.

WEST VIRGINIA

West Virginia requires HMOs to cover basic health care services, including infertility services, when medically necessary. The West Virginia Insurance Commissioner does not define infertility services.

 

Diagnosis and treatment of infertility and IVF: am i covered?

How to check infertility and IVF covered by insurance?

We have listed questions to ask your health insurance company, HMO (Health Maintenance Organization), or employer (Human Resources or Benefits Department), to help you evaluate your infertility and IVF benefits. Many self-insured companies may offer Infertility and IVF Benefits. Click here to see a list of such companies. We recommend that you verify the answers you receive.

To do this, simply call the company 24 hours or so after the initial phone conversation, and ask another representative the same questions. If the answers do not agree, send a email or letter to the company stating exactly what you understand your benefits to be, and request that they reply with a written confirmation of this information.

Contacting your employer or insurer

Before calling your insurance company, HMO, or employer, have this information at hand:

  • Name of the insured individual
  • Employee/Patient ID # or Social Security #
  • Name of employer
  • Name of plan
  • Group code/number
  • Patient’s name and date of birth

Be sure to get the name of the person to whom you are speaking and his or her telephone and extension numbers. Answers to the following questions will help you understand which infertility and IVF procedures will be covered and reimbursed during the course of your therapy for infertility. The information you obtain will also be useful to the insurance counselor at your doctor’s office. Remember, if you are unsatisfied with the answers you receive, ask to speak to a supervisor or to another representative who is more familiar with the infertility and IVF benefits.

Questions for your employer (humanresources or benefits representative):

1.Are infertility and IVF treatments covered on my current health plan?

2.Is there another plan that has infertility and IVF coverage? If so, what is the cost difference, can I change plans, and when can I change plans?

3.Are there restrictions to the infertility and IVF benefits?

4.What is the waiting period before I can start treatment for pre-existing infertility and IVF conditions?

Questions for your insurance company:

  • What are my infertility benefits?
  • What is excluded?
  • Is there an age restriction for infertility and IVF treatment? If so, what is it?
  • What do the infertility and IVF benefits cover?

– Do they cover infertility and IVF diagnostic procedures?

– Do they cover infertility and IVF treatment procedures?

– Do they cover infertility and IVF drug therapy?

  • Which of the following are covered?

– Blood work?

– Progesterone and estrogen levels?

– FSH, LH, TSH, and prolactin levels?

– Semen analysis?

– Endometrial biopsy?

– Post-coital test?

– HSG (hysterosalpingogram)?

– Ultrasound?

  • Which drugs are reimbursable?

– clomiphene citrate, eg, Clomid®*? (clomiphene citrate tablets, USP)

– gonadotropin releasing hormone antagonists or agonists, eg, Ganilerix

Acetate Injection™?

– hMG (human menopausal gonadotropin)?

– hCG (human chorionic gonadotropin), eg, Pregnyl® (chorionic gonadotropin for injection, USP)?

– FSH, eg, Follistim® (follitropin beta for injection)?

  • Do I need to use specific pharmacies or mail-order pharmacies?
  • What types of infertility and IVF treatments are covered?

– IUI (intrauterine insemination — ie, artificial insemination)?

– IVF (in vitro fertilization)?

– GIFT (gamete intrafallopian transfer)?

– ZIFT (zygote intrafallopian transfer)?

– ICSI (intracytoplasmic sperm injection)?

  • Do I need a referral for infertility and IVF diagnostic procedures?
  • Do I need a referral for infertility and IVF treatment?
  • Do I need to undergo specific tests before being referred to a specialist?
  • How do I get a referral?
  • Do I need a precertification?

– What does the precertification cover?

– How do I get a precertification?

– For how long is the precertification valid?

  • Do I have a lifetime maximum benefit?

– If so, what is the limit?

  • Do I have a calendar year maximum benefit?

– If so, what is the limit?

  • Is infertility therapy included in the lifetime maximum benefit?
  • Is infertility therapy included in the calendar year maximum benefit?
  • What are the maximum allowed attempts for non-IVF procedures, such as ovulation induction and IUI?
  • What are the maximum allowed attempts for ART procedures (ie, IVF, GIFT, ZIFT, and ICSI)?

– Does this number include only stimulation cycles or does it also include thaw cycles for embryos?

  • Are freezing and thawing charges for embryo cryopreservation covered?
  • Does the plan have a discounted rate for additional ART cycles?
  • Are donor sperm and/or egg options covered?
  • Is the egg donor covered by my plan if she has complications?
  • Am I restricted to using certain specialists and ART (assisted reproductive technology) centers?
  • Do you have any physician profiles or comparative data to help choose a physician or ART center?
  • Who can I contact at my plan’s affiliated reproductive medicine clinics/programs to get more information about the services offered?
  • Which infertility and IVF clinics does the plan use for ART procedures?

– Am I restricted to using these clinics?

  • Does the plan contract with outside providers to do vaginal ultrasounds or lab work?

– If so, which ones?

  • Which hospitals are affiliated with my plan?
  • Will the plan pay for me to get another medical opinion from a physician outside the health plan?