Insurance Coverage for Infertility Care

It is no secret that infertility treatment can be costly (an average of $12,400 per IVF cycle), yet only 15 states mandate insurance coverage for infertility care. According to a 2014 National Health Statistics Report, about 12 percent of U.S. women of childbearing age (or their husbands or partners) have used infertility services.

FERTILITY FRIENDLY STATES

There are wide discrepancies in infertility coverage and treatment accessibility from state-to-state. While some states, including New Jersey, are considered “fertility friendly,” others either do not mandate infertility care or have limited mandates that cover testing and diagnosis, but not the actual treatment.

State mandates are laws that require health plans sold by licensed insurers to include coverage for specific benefits, in this case, infertility care. Fifteen states – Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia, have mandates requiring insurers to offer coverage or cover infertility treatment and diagnosis

The top states for fertility benefits, according to Resolve, a nonprofit focused on reproductive health, include Connecticut, Illinois, Maryland, Massachusetts and New Jersey.

NEW JERSEY STATE MANDATE

Since 2001, the state of New Jersey has required all health insurers that cover groups of 50 or more to provide hospital or medical benefits for medically necessary expenses incurred in the diagnosis and treatment of infertility. These services must be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

The mandate requires the same copayments, deductibles, and limits are applied to infertility benefits as to other medical or surgical benefits. A separate copayment, coinsurance, deductible, dollar maximum, visit maximum or procedure maximum may not be imposed on any infertility treatment with the exception of limiting infertility coverage to four completed egg retrievals per lifetime for the covered person.

Religious employers may exclude specific coverage when it is contrary to their tenets or doctrine. Written notification of these exclusions must be provided to all prospective insured or covered persons.

UNDERSTANDING CO-INSURANCES AND DEDUCTIBLES

Even when diagnosis and treatment of infertility are covered by insurance mandates, certain personal costs often apply. This may include the following:

• Copay (copayment) – A fixed amount billed to the insured person for a covered service. This fee is typically required at the time of the visit. The amount varies depending on the particular policy. Some plans may have a $20 copay, while others are half that amount. The higher the monthly insurance premium, the lower the copayment. If an individual has not met the deductible for that year, they may be required to pay the full deductible fee before receiving service
• Deductible – The annual amount you pay out-of-pocket for covered health care services before your health care plan kicks in. If a plan’s deductible is $2000, the insured individual must pay that amount each year before the insurance plan begins to pay their portion covered healthcare services
• Coinsurance – This is a rate an insured individual is expected to pay essentially splitting the cost of healthcare with the insurance company. The rate might be 80/20, in which case, the insurance company would cover 80 percent of any covered expense, while the individual picked up the remaining 20 percent. Other rates might be 90/10, 70/30 and so on. Many major health insurers place a coinsurance cap on expenses individuals are expected to pay in the case of catastrophic illness. This protects the individual from financial distress. Caps vary from plan to plan and may be as low as $1000 or up to a maximum of $2000 or $3000 per year. Once an individual reaches the designated cap for that year, they are not required to contribute any additional monies toward the copay.

INSURANCE SAVVY

It is important to become familiar with the infertility mandates in your state and to develop an understanding of your personal health insurance policy concerning infertility care. This knowledge will help you prepare for upcoming expenses and may also determine the affordability of infertility diagnostic testing and treatment.