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How Obamacare Will Affect Infertility Insurance Mandates

December 30,2013

According to a study conducted in 2006 by RESOLVE: The National Infertility Association, just 20 percent of employer-sponsored health insurance plans offered coverage for fertility treatment. Now, with the launch of the Affordable Care Act (ACA) in 2014, colloquially known as Obamacare, fewer patients will be provided insurance coverage for fertility treatment.

Currently, fifteen states mandate some degree of fertility coverage. The degree of coverage varies from state to state, however, and there are loopholes such as number of employees and religious affiliation which could exempt an employer from the mandate. Come January 1, there will be a complete overhaul of the health care system and infertility insurance coverage is no exception.

Under the Affordable Care Act, the following ten essential health benefits will receive mandatory coverage beginning in 2014:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

The good news here is that routine OB-GYN examinations, blood work, and prenatal care/screening will be covered. Obamacare will eliminate “pre-existing condition” exceptions to treatment and will set limits on how much insurers can charge for insurance premiums.

The bad news is that infertility treatment is very unlikely to be covered despite current state mandates. The National Conference of State Legislatures website states: “the ACA does not directly alter or preempt state mandates; however, starting 2014, if states elect to include certain services in qualified health plans to exchange enrollees not included in the ‘essential health benefits,’ the state will have to pick up the cost.” This means that any mandates proposed by the state that are not listed under the ten federal EHBs will have to be covered at the state’s expense.

Regarding Flexible Spending Accounts (FSA), contributions will be capped at a maximum of $2,500 per year and tax deduction opportunities are also likely to be minimized.

This will surely change the way fertility patients pursue treatment, particularly the number of patients pursuing in vitro fertilization (IVF) due to the higher cost of this treatment (on average $12,400 per cycle in the United States).

You may also be interested in: Fertility Treatment Costs

To read more about the ACA and infertility insurance, click here.

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