Like other types of insurance coverage, many people are unaware if they have insurance for infertility treatment until they find themselves in need of using it. Some may have coverage but are unaware of the limitations or restrictions. The reality is that insurance coverage varies greatly depending on the state, the medical situation, the treatment, and the individual. And the exceptions can make holes big enough to drive trucks through.
According to American Society for Reproductive Medicine, there are 15 states that have some form of insurance coverage requirements for treatment. Most of them cover treatments (Arkansas, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia) while others “offer coverage” (Texas and California). The coverage mandate in some states includes in vitro fertilization (IVF), in other states it excludes IVF, and in others it includes only IVF. Moreover being in a state with a mandate that includes IVF (or anything else) does not mean that your employer will provide coverage. Many employers are exempt from the law for a variety of reasons.
In addition to exemptions that can entirely eliminate any infertility coverage, insurance may not cover certain treatments or fertility drugs in all cases. The coverage may have specific medical requirements, limitations on methods, age requirements, caps on number of cycles or lifetime spending limits.
IVF procedures are usually performed after prepayment which means a large out-of-pocket expense since the average cost is $12,400. In a state without a mandate or if the employer doesn’t provide the coverage for whatever reason, that is a potentially roadblocking cash payment standing in the way of a possible solution to infertility. Someone with insurance coverage of 50% for infertility treatment still has to pay $6,200 cash or equivalent for treatment. That is not small change.
Insurance coverage can be helpful and some coverage is better than no coverage. However there are many exclusions, exceptions, hurdles and holes which often make it less effective. The result is that for many people experiencing infertility, insurance is no solution to the expense of infertility.
[For the chart of insurance coverage by state, see American Society for Reproductive Medicine Insurance: http://www.asrm.org/detail.aspx?id=2850]