How will Obamacare affect infertility treatment coverage?
Infertility can be emotionally and financially devastating — and patients won’t be able to count on the federal health care reform law to make treatment more affordable.
The Affordable Care Act, commonly known as Obamacare, doesn’t specifically address infertility and it doesn’t require health insurance plans to cover treatment, says Sean Tipton, director of public affairs for the American Society for Reproductive Medicine (ASRM).
What is infertility?
Infertility, the inability to either conceive or to carry a baby to delivery, affects 7.3 million married U.S. women – 12 percent of the reproductive-age population, ages 15 to 44, according to the National Survey of Family Growth conducted by the U.S. Centers for Disease Control and Prevention.
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Infertility can be caused by various factors – for example, irregular or abnormal ovulation in women or low sperm count in men. Treatments can include drugs, surgery or procedures such as in vitro fertilization (IVF), in which eggs are fertilized outside the body and the resulting embryos are implanted into the uterus. One cycle of in vitro fertilization costs an average of $12,400 and some patients need multiple cycles, according to the ASRM.
Right now, many patients have to pay for infertility treatment out of pocket or choose a treatment based on insurance coverage, Tipton says. For example, a woman with endometriosis, a disorder in which uterine lining tissue grows outside the uterus, might have a difficult time getting pregnant due to problems such as scarring and inflammation, according to the ASRM. She might choose to have surgery for her endometriosis, to remove some of the endometriosis and scar tissue, because her insurance company covers it.
But if after the surgery she still is having trouble conceiving, she might choose not to follow the surgery with IVF, even if her doctor recommends it, because her insurance company doesn’t cover that treatment.
Currently, most states don’t require health insurance companies to cover infertility treatment in general or specific procedures to treat it, experts say. Only 15 states, including Connecticut, Illinois and Ohio, mandate that insurers either cover or offer coverage for infertility. And eight states, including New Jersey and Maryland, require coverage for IVF, says Barbara Collura, president and CEO of RESOLVE: The National Infertility Association.
Outside of those states, coverage varies widely. For example, a 2006 survey conducted by health benefits firm Mercer Health and Benefits showed that large-group health plans often don’t cover infertility treatment. Out of plans offered by U.S. employers with 500-plus employees, 54 percent covered evaluation by an infertility specialist, 37 percent covered infertility drugs, 19 percent covered IVF and 10 percent covered other advanced procedures, according to the report.
Infertility should be treated like any other disease, Tipton says: “You have health insurance so you can get the care you need if you get sick.”
How will Obamacare affect infertility coverage?
Experts don’t yet know how the ACA will affect infertility coverage mandates that currently exist, Collura says. Those states can add infertility coverage as an essential health benefit in plans sold in their exchange – health insurance marketplace – or they can drop the mandate, she says.
So far, two states with mandates have made decisions on infertility coverage:
• In Maryland, the current mandate requires individual and large group insurance plans that cover pregnancy to also cover infertility treatment if the patient meets certain requirements. For example, the patient and spouse must have had infertility for two years or the infertility must be associated with a certain condition, such as endometriosis. Maryland has decided to include infertility treatment as an essential health benefit in plans sold in its exchange.
• In Massachusetts, all insurance plans that cover pregnancy are required to cover infertility with no limits, except for experimental procedures. Infertility is defined as being unable to conceive within one year. Massachusetts will keep infertility treatment as an essential health benefit.
However, consumers who live in states with no mandate can expect the status quo to continue, experts say. Of patients in non-mandate states, Collura says, “The ACA doesn’t hurt them and it doesn’t help them.”
So what will Americans with infertility do? “Pay out of pocket – that’s what people have been doing for years,” Tipton says.
Paying for infertility treatment, even with insurance, can cause a big financial burden for families, says Davina Fankhauser, president of the support and advocacy group Fertility Within Reach.
When Fankhauser faced infertility, she lived in a state with a mandate, but her husband’s employer was exempt from the requirement to cover infertility because the company was self-insured. She bought a $600-a-month individual policy that covered infertility but she and her husband still had to pay over $35,000 for cost sharing and procedures such as genetic testing that weren’t covered. “I was saving every dollar to try and build my family,” she says.
While health care reform likely won’t help patients with infertility get evaluation or treatment, a few provisions in the ACA will help these patients in three other ways:
1. The ban on denying coverage to adults with preexisting conditions, which goes into effect in 2014, means patients with infertility will be able to get individual health insurance, experts say. Now, many insurers consider infertility a preexisting condition and deny coverage to patients with infertility, even when they were successfully treated years earlier.
2. Insurers now are required to offer preventive care, including screening for sexually transmitted infections, with no cost sharing. And according to the CDC, untreated chlamydia and gonorrhea can cause infertility.
3. Maternity and newborn care are essential health benefits required by the ACA, and this will help women who become pregnant through infertility treatments such as artificial insemination or IVF. “The minute a woman is pregnant, maternity care kicks in,” Collura says.
But experts say insurers could end up paying a lot more for high-risk pregnancies when they don’t cover infertility treatments such as IVF, which allows a woman and her doctor to decide how many embryos to implant. That’s because patients might opt for less expensive treatments, such as fertility drugs combined with artificial insemination, that carry a higher risk of getting pregnant with multiple babies. These pregnancies, in turn, carry a higher risk of complications.
Even with IVF, patients paying out of pocket might only be able to afford one treatment cycle, which could mean a higher likelihood of becoming pregnant with twins, triplets or more, Fankhauser says. That’s because a patient with insurance coverage for infertility might choose to have one embryo implanted, then go through another cycle if the first doesn’t work or if she wants another baby later, she says. But that’s often not an option for self-pay patients. Fankhauser says: “They’re going to transfer every embryo, hoping for their instant family.”