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Health Insurance Plans Weigh Covering Fertility Treatment Costs

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A panel of experts brought together by the Institute of Medicine is weighing the issue of whether fertility treatment costs should be covered by the new state-based insurance exchanges that will be available in 2014 for individuals and small businesses.

The question at hand? Should fertility treatments be considered essential health benefits, or are they more “life-enhancing,” since they don’t treat life-threatening illnesses?

Currently, infertility insurance coverage remains spotty at best. There are only 15 states that require insurance plans to offer coverage for fertility treatments. And even these infertility insurance mandates aren’t a cure-all — many have stipulations in place that exempt small employers and large employers who self-insure, as well as exclude certain fertility treatment procedures. For example, New York excludes IVF, GIFT, and ZIFT from its requirement, and Texas requires that the patient’s egg be fertilized by her husband’s sperm, which excludes same-sex couples.

According to the 2005 survey Mercer’s National Survey of Employer Sponsored Health Plans 2005, just over one-third of employers with 500 or more employees cover fertility drug therapy, 20 percent cover IVF, and only 10 percent cover other advanced reproductive procedures like GIFT or ZIFT. Small businesses are even less likely to provide insurance coverage for fertility treatment costs.

So what would happen if insurance plans were required to provide coverage for fertility diagnostics and fertility treatments?

“I think that there is no question if fertility care were included under the law, more people would be able to access basic fertility care and IVF,” says Dr. David Adamson, a board certified fertility doctor at Fertility Physicians of Northern California. “And it’s important to recognize there is a lot of care that doesn’t include IVF — there are cheaper alternatives.”

When Insurance Plans Don’t Cover Fertility Treatment Costs

But right now, many couples who have had difficulty trying to conceive, or who have already been diagnosed with infertility, are stuck in a difficult financial situation. Since many of their private insurance plans don’t provide coverage for fertility treatments, they are left looking for other options to finance their fertility treatments.

Of course, couples with a high enough income can use their own resources, but many others turn to credit cards, liquid assets or property they can mortgage. Others look to take out second mortgages, home equity loans or unsecured personal loans. Depending on relationships with family, some couples may ask parents, grandparents, or other family members to lend the money for their fertility treatments.

Some fertility clinics and independent organizations also offer special fertility financing plans, many that provide loans or payment plans to help pay for fertility treatments. Other fertility clinics offer IVF Refund Programs, in which patients pay a flat fee up front for a set number of IVF cycles, but receive a certain percentage back if they do not conceive.

“And a final, unfortunate choice is not to have children,” Dr. Adamson says. “A lot of them end up not having any kids.”

Should Fertility Treatment Coverage Be Mandated by Law?

According to Vicki L. Baldwin, the President and CEO of In Vitro Sciences, Inc., the answer to whether fertility treatment costs should be covered as part of the new insurance plan depends on two issues.

“The first is, is this an important issue for people in general, compared to a life-threatening issue. Anyone who has gone through it would say that it’s a life crisis,” she says. “Then you have to ask, how big of a life crisis? Look for data on it, such as how it affects productivity."

The second issue asks whether adding fertility treatment coverage to insurance plans will increase total health care spending, including the delivery of babies, the delivery of multiples and lifetime care.

“For example, PGD (preimplantation genetic diagnosis) is used to prevent the births of babies with serious genetic diseases,” Baldwin says. “If that were covered, it can reduce the number of babies born with lifetime genetic problems, which could reduce total health care spending.”

According to the Mercer survey, the overwhelming reason organizations say they do not offer fertility treatment coverage is cost issues. However, over 90 percent of organizations that do offer fertility treatment coverage report that they have not experienced a measurable increase in their medical costs as a result of adding that coverage.

Dr. Adamson points out that fertility treatment cost and emotional stress issues are the top barriers that prohibit couples from seeking fertility treatment. Helping to solve the cost problem would be a helpful step.

“I certainly think that infertility is a disease — it has been defined by the World Health Organization as a disease,” he says. “Not only is it defined as a disease, but on a commonsense look, when comparing it to other conditions that are covered, I think that infertility coverage should be included.