Even with health insurance, prepare to pay thousands of dollars for infertility treatment
Lisa Jaffe Hubbell
For those who can’t conceive naturally, fertility treatments provide an alternative — albeit a costly one.
Fifteen states require some level of health insurance coverage for infertility diagnosis and treatment, according to the National Conference of State Legislatures. But don’t get too excited if you live in one of them. Even with insurance coverage, big obstacles and big costs likely will stand in the way of motherhood or fatherhood.
Some state laws include waiting periods, and some don’t mandate enough coverage to pay for the entire treatment. Some exclude certain procedures, like in vitro fertilization (IVF). Other laws fail to define what infertility means or what treatment entails, which can complicate matters when dealing with health insurance claims.
|Millions of Americans cope with infertility — and with paying for infertility treatments.|
Only about 10 percent of health insurers cover IVF, according to the InterNational Council on Infertility Information Dissemination. At least 5 million American couples are infertile, the council says; of those, about 2 million can’t conceive without IVF. An estimated 7.3 million Americans are affected by infertility, according to RESOLVE: The National Infertility Association.
The IVF procedure and its associated medication can cost roughly $10,000 to $15,000 per couple, the infertility council says.
Several states have laws that require insurers to tell potential policyholders that insurance for infertility is available in the state — but don’t require insurers to actually provide it.
In California, for example, insurers must inform group insurance providers (namely employers) that infertility coverage is available from some insurance companies in the state, according to the infertility council. Yet these insurers actually don’t have to offer infertility coverage themselves. And even if they do offer coverage, employers don’t have to include infertility coverage in the insurance packages they offer their workers.
Here are the 15 states that have laws regarding health insurance coverage for infertility diagnosis and treatment: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia.
Buying extra coverage
If a policy does not cover IVF, it may be possible to add a rider, which will provide coverage for something not included in your standard health insurance plan. But the cost can be prohibitive. Deductibles and co-payments might be involved as well.
Nancy Hemenway, executive director of the InterNational Council on Infertility Information Dissemination, says: “Often, you are better off saving your money and paying for the treatment yourself, because a policy or rider will cost too much if you have already been diagnosed as having a fertility issue. And if you don’t admit the diagnosis, that’s insurance fraud.”
Cases in point
Massachusetts has one of the more generous laws when it comes to infertility coverage. All insurers offering pregnancy benefits must cover diagnosis and treatment of infertility as well, according to the National Conference of State Legislatures.
When Cheryl Alkon and her husband had their first child, she opted out of her husband’s policy — which didn’t cover IVF — as well as out of her employer’s policy, which originated in Pennsylvania and wasn’t subject to the Massachusetts regulations.
Instead, Alkon bought a policy on the individual market to cover her IVF treatment, doctor’s bills and artificial insemination. It didn’t cover her medications, however, which resulted in out-of-pocket costs of about $2,000, in addition to her monthly premiums. The couple had a second child under a different policy offered through Blue Cross Blue Shield of Massachusetts. That policy, at $500 a month, did cover medications, as well as up to six attempts at IVF.
Meanwhile, Melinda Chan and her husband had coverage through Microsoft when she underwent infertility treatments. The company provided $15,000 coverage for IVF treatment — but the diagnosis and drug coverage were separate from that amount. Chan estimates she spent about $4,000 in out-of-pocket expenses for two rounds of IVF.
Even when coverage is mandated and offered, the mechanics of infertility treatment can be daunting. And they might be designed to keep couples from using the benefits, Hemenway says.
“I worked with a couple where the husband had a vasectomy and the reversal wasn’t successful,” she says. “Since he’d had a vasectomy, the insurance company tried to say they weren’t infertile and they didn’t have to cover IVF.”
That couple ended up accessing the benefits by using the wife’s endometriosis as the reason for infertility.
What should be covered?
The infertility council’s Hemenway says state-mandated coverage isn’t foolproof, as insurers do look for ways around it.
“I’d rather see (coverage) as voluntary, in part because a lot of reproductive endocrinologists don’t want to deal with the hassle of insurance and the reduction in fees that the (insurance) companies negotiate,” she says.
RESOLVE supports state and federal legislation that would require insurers to cover the costs of “appropriate” medical treatment for infertility.
“Public policymakers, employers and insurers have been slow to recognize infertility as a disease. The time to change this is now,” the group says on its website.
Infertile couples “should not have to spend their life savings, second mortgage their home, or incur thousands of dollars of debt to treat a disease and to fulfill a fundamental aspect of life the desire to bear children and raise a family,” RESOLVE says.
For more information about infertility treatment, visit the websites of these organizations: