According to the Department of Health and Human Services, many people in the US have experienced problems with their fertility. Their statistics show that approximately 9% of men and 11% of women are affected.
Thanks to the Affordable Care Act, millions of US citizens now enjoy greater health insurance coverage. If you’re struggling with fertility problems, you might be curious whether the ACA has made fertility treatments more accessible and affordable.
Are you hoping to start a family soon? Find out what you need about fertility treatment and the Affordable Care Act in the article below.
What Is IVF?
One of the most common infertility treatments is in vitro fertilization or IVF. This fertility treatment entails fertilizing an egg with sperm, in vitro or outside the human body, usually in a test tube. In vitro is the Latin term for “in glass.”
The egg cells or ova and sperm cells are harvested in a medical facility, and fertilization occurs in a lab-controlled setting. Before this takes place, however, the female partner’s ovulation will be monitored and, if necessary, stimulated to produce ova for collection.
Obamacare And IVF
Obamacare (the more common name used for ACA health insurance plans) regulates what major medical plans must offer in their coverage of prenatal and newborn care.
The federal government doesn’t require insurance companies to offer fertility coverage to Americans. It also doesn’t need US businesses to provide employees with this health insurance coverage.
However, you can still get insurance that covers fertility treatments and services like IVF. It just means that the ACA does not require it at the federal level. Some states have passed additional mandates that require insurance plans to cover IVF treatments.
The extent to which IVF treatments are covered under Obamacare can vary significantly from state to state due to a combination of federal and state-level regulations, mandates, and choices made by insurance providers.
States That Require Health Coverage For Infertility Treatment
At the time of writing, 19 states require their state-regulated plans to offer at least some coverage for infertility treatments. These are:
Arkansas
California
Colorado
Connecticut
Delaware
Hawaii
Illinois
Louisiana
Maryland
Massachusetts
Montana
New Hampshire
New Jersey
New York
Ohio
Rhode Island
Texas
Utah
West Virginia
However, the degree of coverage and the type of fertility issues or infertility treatments covered vary. Some states don’t require their plan to cover in vitro fertilization (IVF) or fertility medications. In contrast, others have specific diagnosis requirements or require only fertility coverage on particular plans.
Examples Of Differences Between States
New Jersey is considering legislation covering ovulation-enhancing medications under the state’s Medicaid program. Utah’s infertility coverage requirement is a three-year pilot program that applies to Utah’s Public Employees’ Health Plan. It also requires insurers to offer maternity benefits that people can use to fund infertility treatment.
In California, Illinois, New Hampshire, and Texas, coverage for infertility treatment is only required on group plans and not individually purchased policies. Colorado offers coverage for large-group health plans and may soon offer this coverage on individual and small-group plans, too.
In 2024, Maine and Kentucky will join the list, but in Kentucky, coverage will only be required for egg and sperm preservation before a medically necessary treatment is expected to cause infertility.
Fertility treatment coverage legislation for state-regulated plans is also under consideration in the District of Columbia, Missouri, Oklahoma (fertility preservation only), Oregon, Virginia, and Washington.
Benchmark Plans
A benchmark insurance plan is a model for the minimum level of coverage that individual and small-group plans must provide policyholders. There are some differences between the fertility coverage offered on these benchmark plans.
When looking at the benchmark plans for the states that currently have mandates on fertility coverage, these differences come to the fore.
- New Hampshire and West Virginia include infertility diagnosis and treatment of the underlying causes of infertility.
- In Texas, the benchmark plan includes coverage for infertility diagnosis but not treatment.
- Colorado’s benchmark plan’s fertility treatment coverage is limited to infertility diagnosis and artificial insemination. The same goes for Montana and New York.
But even in the absence of a state mandate on fertility coverage, some states have benchmark plans that offer it, although it may be limited. These states are Arizona, DC, Iowa, Michigan, Missouri, Nevada, New Mexico, North Carolina, Pennsylvania, Tennessee, and Virginia.
- Arizona, DC, and Tennessee only include coverage for infertility diagnosis in their benchmark plans.
- Michigan, Missouri, New Hampshire, New Mexico, and Virginia’s benchmark plans include infertility diagnosis and treatment of the underlying causes of infertility.
- Pennsylvania and Nevada only include infertility diagnosis and artificial insemination.
- Iowa and North Carolina’s benchmark plans only include infertility diagnosis and medical stimulation of ovulation.
Always consult the fine print when considering any health plan, including benchmark plans, as state mandates on fertility coverage can change.
The Cost Of IVF Without Insurance
Even if it’s not illegal to not have health insurance, you may not want to risk going without it. In the US, a cycle of IVF can cost as much as $30,000 without insurance. This is why you must consider medical insurance’s importance when creating a family.
The best way to secure a medical insurance plan that covers this need is to look at one of the ACA-regulated health insurance plans on the market. It can be confusing when looking through all the insurers and their different plans, though.
How do you know which one will meet your needs for fertility treatment? This is where trusted health insurance brokers, like Enhance Health, are invaluable. By discussing your budget and fertility needs with your broker, you’ll get the coverage you need at a price you can afford.
The Cost Of IVF With Insurance
IVF treatments are often done in cycles, and for the first cycle, the average couple may be looking at expenses of $12,00 to $15,000 with insurance.
However, although a good insurance plan can absorb many fertility-related costs, the exact degree of coverage will differ. But remember to keep in mind that not all plans cover IVF treatments so be sure to check your coverage.
Connecticut, Hawaii, Illinois, Maryland, and Massachusetts’s benchmark plans include reasonably comprehensive coverage of fertility treatments, including IVF.
Alternatives To IVF
Most people think of IVF when considering help with planning a family. However, IVF is not your only option if you cannot conceive naturally. Except in extreme cases, you will usually have more than one choice in fertility treatment.
Your choice will depend on whether you cannot conceive or have trouble conceiving naturally. If you are uncertain about the cause of your delayed conception, you’ll need a diagnosis of infertility and an investigation into the underlying causes.
While your doctor may recommend IVF, intrauterine insemination, ovulation induction, fallopian tube surgery, and fertility medications may work for you, too. It all depends on the cause of the infertility or difficulty with conception.
Understanding Your Health Insurance Policy
When it comes to fertility treatments and health insurance policies, there are a few possible categories that these plans can fall under:
- No coverage for fertility-related issues: Health insurance plans provide no financial assistance or coverage for fertility-related issues. This means that individuals are responsible for covering their infertility diagnosis and treatment costs.
- Infertility diagnosis only (no fertility treatments): Some insurance plans offer coverage exclusively for infertility diagnosis. They will pay for the tests and consultations necessary to identify fertility issues. Still, they do not extend coverage to any fertility treatments or medication.
- Infertility diagnosis and limited coverage for fertility treatments: In this category, insurance plans cover infertility diagnosis and some fertility treatments, but with limitations. The extent of coverage may vary, and there could be restrictions on the types of treatments covered, the number of treatment cycles, or the total financial cap on expenses.
- Full coverage (diagnosis and all treatments): The most comprehensive category includes insurance plans that offer full coverage. These plans cover the costs of diagnosing infertility issues and the range of fertility treatments available. This can encompass services like IVF, intrauterine insemination (IUI), medications, and other necessary medical interventions. However, specific coverage details may still vary from one plan to another.
- Medication coverage may or may not include fertility-boosting drugs like oral ovulation drugs or injectable fertility drugs.
Of course, you may discover difficulties conceiving after signing up for a health insurance plan. But if you are yet to choose a policy and know you’re planning to start a family, you must understand what it covers and doesn’t.
If your plan falls into the category of limited coverage, it’s up to you to ask for the finer details of what this means before signing up for that policy.
Conclusion
Does the Affordable Care Act mandate that health insurance cover fertility treatment? No. Whether or not an ACA-compliant plan covers fertility treatments is up to the insurer and the specific outline of that policy.
This is why, when choosing an insurance plan and needing it to cover fertility treatment, it’s best to get professional help. Our team of consultants is standing by to assist you with expert advice, choosing a plan, and signing up.
Contact us today for the stress-free medical insurance sign-up with fertility treatment coverage that’s best for you.
