States Laws & Coverage for Fertility Treatments & Medication
People affected by infertility have options to try, but in vitro fertilization (IVF) and diagnostics, medications, surgery and other treatments can be expensive. In some cases, medical insurance will cover a large portion of the costs, but in other cases, it will not.
Globally, 15% of couples of reproductive age are affected by infertility worldwide, according to estimates by the World Health Organization (WHO). The majority of people affected by infertility (including men, women, LGBTQ couples and singles) will pay disbursed. Depending on the treatment, out-of-pocket costs can easily run into the thousands of dollars.
Some states have laws that require insurance companies to cover infertility treatment, but the laws vary. Here we will explain in more detail how state laws affect insurance coverage for fertility treatment.
Key points to remember
- Mandatory insurance coverage for fertility treatments and medications is not widespread in the United States
- Many insurers do not consider these health services to be “medically necessary”.
- Fifteen states have laws that require specific private insurers to cover infertility treatment.
- Same-sex couples often face greater barriers to accessing fertility treatment coverage.
What is included with fertility treatment
The type of fertility treatment prescribed by a doctor will depend on the needs of the individual or couple. Common fertility treatments include:
- Medication: Certain medications, such as clomiphene citrate and letrozole, may help treat infertility in women by stimulating ovulation. Other medications may be prescribed in conjunction with fertility treatments, such as in vitro fertilization (IVF).
- Intrauterine insemination: Intrauterine insemination, also known as artificial insemination, involves inserting sperm into the uterus. Sometimes medications are also prescribed to help stimulate ovulation before the procedure.
- In Vitro Fertilization (IVF): IVF is a type of assisted reproductive technology that involves fertilizing an egg outside the womb and returning the embryos to the womb.
- Operation: Surgical procedures such as laparoscopy and hysteroscopy may be indicated to diagnose infertility in women or to resolve potential obstacles to conception, such as endometriosis or uterine fibroids.
State Laws on Fertility Treatments
Fifteen states require insurance cover for fertility treatment, according to the Kaiser Family Foundation. They understand:
- Arkansas: obligates individual and group insurers to provide coverage, but not HMOs and self-insurers.
- Connecticut: obligates all health insurers to provide coverage. Religious employers and self-insurers are exempt. Additionally, people must be on the plan for more than 12 months to be eligible.
- Delaware: has a coverage mandate that excludes employers with less than 50 employees, religious employers and self-insurers.
- Hawaii: requires individual and group insurers to provide coverage, but self-insurers are exempt.
- Illinois: excludes employers with less than 25 employees, religious employers and self-insurers from its laws.
- Maryland: requires coverage with a few exceptions: employers with less than 50 employees, religious employers and self-insurers.
- Massachusetts: the law excludes self-insurers from the coverage requirement.
- Montana: obliges HMOs to cover fertility treatments.
- New Hampshire: the exemptions to its requirements are slightly different from those in other states. Self-insurers are exempt, along with the extended transition to ACA programs and the Small Business Health Options (SHOP) program.
- New Jersey: law provides an exemption for employers with less than 50 employees, religious employers and self-insurers.
- New York: the law does not require individual and small group markets to cover IVF, and self-insurers are exempt from state coverage laws.
- Ohio: requires HMOs to provide coverage; self-insurers are exempt.
- Rhode Island: the law requires insurers, including HMOs, to provide coverage, but self-insurers are exempt.
- Utah: the law, as in other states, does not require self-insurers to provide coverage for fertility treatment.
- West Virginia: only requires HMOs to provide fertility treatment coverage.
California and Texas have laws that require insurance companies to provide coverage, but employers are not required to select insurance plans with this coverage. States may also have age limits for eligibility.
Factors that affect fertility treatment insurance coverage
Infertility is generally defined as the inability to conceive after one year of unprotected heterosexual intercourse. Insurance companies often use a definition like this to determine when people may become eligible for fertility treatment coverage. Fertility insurance may cover a wide range of fertility treatment services or just a few services.
If you have insurance through your employer, the size of the company you work for plays a role in whether or not you have access to coverage for fertility treatments. Many states that have laws requiring insurance companies to cover fertility treatments provide exemptions for employers with fewer than 50 or fewer than 25 employees. Additionally, employers who fund their own insurance are not required by state law to provide coverage for fertility treatment.
More and more large employers are choosing to offer this type of coverage. In 2015, 36% of companies with 20,000 or more employees offered IVF coverage. In 2020, this number has increased to 42%.
If you have health insurance through the exchange, keep in mind that the Affordable Care Act (ACA) does not require insurers to provide coverage for fertility treatments.
Much of the conversation around fertility treatment coverage focuses on heterosexual couples trying to conceive. But same-sex couples and single women also turn to fertility treatment when planning family planning, often facing more barriers to access. Discrimination lawsuits against major insurers could make it easier for LGBTQ people to access fertility treatments.
Ask your employer what type of insurance plan they offer. An employer with a self-funded plan is not required to follow state insurance laws, which may mean that your plan does not provide coverage for fertility treatments.
Does insurance cover fertility treatment?
Whether or not your insurance helps pay for fertility treatments depends on several factors, including the state you live in, your insurance company, and your employer.
How much do fertility treatments cost?
The average cost for a single cycle of IVF is around $12,400, according to the American Society of Reproductive Medicine. Many people need several cycles of IVF before becoming pregnant. The cost of fertility treatments depends on where you live, your provider, your insurance, the type of treatment and the length of treatment. Your insurance may cover the cost, but it may not. Only certain state laws require insurance coverage to include fertility treatments.
How many states have laws requiring some sort of insurance coverage for fertility treatments?
Fifteen states require private insurers to cover fertility treatments. The amount of coverage and the type of insurers required to provide coverage differ from state to state.
How does your employer affect your insurance coverage for fertility treatment?
If you have insurance through your employer, you will need to determine your eligibility for coverage. In some states, businesses with fewer than a certain number of employees are not required by state law to provide coverage. If your employer has a self-funded insurance planit will not be subject to state laws requiring fertility treatment coverage.
What kinds of additional barriers to fertility treatment do LGBTQ couples and individuals face?
Same-sex couples and individuals often have a harder time getting insurance coverage for fertility treatments because they don’t meet insurance companies’ definition of infertility. Insurers may require LGBTQ people to pay for multiple rounds of fertility treatments out of pocket before offering coverage.
The essential
Couples and individuals who decide to undergo fertility treatment may or may not have insurance coverage, depending on where they live and what type of insurance they have. Whether you pay out of pocket or with the help of insurance, you can expect fertility treatment to be a significant expense.
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