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Infertility Treatments: Essential or Optional?
Is health insurance coverage of infertility treatments an essential benefit to help people manage a medical disorder? Or is it a life-enhancing benefit, nice to have perhaps but not essential because it doesn't sustain a person's life?
A panel of experts convened by the Institute of Medicine is wrestling with this and other issues raised by the new health-care law. Members are trying to determine what essential health benefits should be included in polices available through the state-based insurance exchanges where individuals and small businesses may buy coverage starting in 2014. The IOM recommendations will go to the Department of Health and Human Services.
Infertility coverage today is generally pretty skimpy. Only about 20 percent of employers cover assisted reproductive therapies such as in vitro fertilization, according to a 2006 survey of 931 employers conducted for Resolve: The National Infertility Association. A majority of employers that didn't offer coverage cited cost concerns, but 91 percent of those that did offer it said it hadn't significantly increased their costs.
About one in eight couples of childbearing age is infertile, according to data from the Centers for Disease Control and Prevention. Insurance coverage, when it exists, varies widely, experts say. Roughly 80 percent of patients who visit Shady Grove Fertility Center, with 13 offices in Maryland, the District and Virginia, have coverage for the initial consultation and tests to diagnose infertility, says Janice Koch, the director of patient financial services.
But coverage for treatment runs the gamut at Shady Grove and other clinics. Some plans cover fertility drugs to stimulate ovulation or intrauterine insemination (IUI, often called artificial insemination) but don't cover pricier assisted reproductive technology (ART) procedures, such as in vitro fertilization. Even if a plan covers IVF, it may cover only a certain number of cycles, or attempts, or cap the dollar amount it will pay for services.
Fifteen states, including Maryland, require that insurance plans cover infertility treatments, according to research compiled by Georgetown University's Health Policy Institute. But mandates often promise more than they deliver, says Sean Tipton, a spokesman for the American Society for Reproductive Medicine, noting that small employers are generally exempt from such rules, as are large employers that self-insure, or pay employee health claims directly.