Insurance Coverage

Insurance Coverage

State Laws

Some states mandate that providers cover infertility treatments while others mandate that providers “offer” coverage (e.g. letting customers know coverage options available to them, but not requiring them to cover it). Currently, the following states require insurance coverage for infertility treatment: Arkansas, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia, while Texas and California laws mandate that insurance plans “offer” coverage.

Exemptions and Inclusions

Even if you reside in one of these states, you may not have a policy that has to adhere to the governing state law. If your employer buys an insurance plan through a health insurance company, state regulations apply. However, if it is a self-funded benefits program, your health coverage is regulated only by the federal ERISA law, which has no provision for infertility treatment. In some cases, employers with few employees do not have to provide coverage. Also, if your employer's policy was not written in the governed state, it may be exempt.

Other plans, such as those purchased by you individually or offered by school districts or religious organizations, may also be exempt from state regulation.

Plans that cover infertility treatment still require thorough research to determine the qualifications associated with that coverage. Not all of these plans will cover in vitro fertilization (IVF) or other assisted reproductive technology (ART) procedures and the medications associated with them. Some plans will only pay for infertility-related expenses after the patient proves a history of unexplained fertility undergoes other cheaper methods of treatment or has a particular diagnosed issue. Further, some plans stipulate age requirements, number of cycles allowed and lifetime maximum reimbursement limits. Find out about your plan by asking your provider how they define “infertility” and what coverage is listed. Learn about restrictions governing the type of specialist you see and if pre-authorizations are necessary. Ask about limits that apply to the coverage in terms of treatment cycles, procedures, prerequisites and drug coverage.

It is difficult to navigate through insurance plans as they vary greatly in what they cover and what they require for that coverage. Take the time to do the appropriate research, so you can take full advantage of what your plan has to offer as well as be prepared financially if that coverage falls short.