Insurance Coverage for Infertility Treatments

For many infertile couples in the United States, the cost of infertility treatment is prohibitive. While many foreign countries, especially those with declining birthrates, subsidize in vitro fertilization (IVF), the United States government has not yet recognized infertility as a disability that warrants greater scrutiny. Luckily for some, however, legislature in 15 states mandates insurers to offer coverage for certain procedures, making infertility treatments more affordable for thousands of families.

Per the American Society for Reproductive Medicine, the following states require insurers to provide coverage for infertility treatment, albeit subject to restrictions:

• Arkansas: Providers cover IVF, but the lifetime coverage may be limited to $15,000. Restrictions apply (e.g., sperm and eggs must not be donated, the couple must have tried to achieve pregnancy for at least two years, etc.).
• California: Providers are not required to cover IVF, but diagnosis of infertility may be covered, as well as gamete intrafallopian transfer (GIFT).
• Connecticut: Both individual and group plans cover medically necessitated diagnosis and treatment of infertility. Restrictions are imposed on patient’s age (must be older than 40), on the maximum number of treatment cycles (four for ovulation induction, three for intrauterine insemination [IUI], and two for IVF, GIFT, zygote intrafallopian transfer [ZIFT], or low tubal embryo transfer), and on the number of embryos transferred (no more than two per cycle). 
• Hawaii: Plans offer a one-time coverage of IVF outpatient expenses. Eggs and sperm must not be donated. The couple must have tried to become pregnant for at least five years. Other restrictions also apply. 
• Illinois: Group plans of at least 25 participants offer coverage for various infertility treatment procedures, but more expensive ones are covered only after less expensive procedures have been attempted unsuccessfully. No more than four egg retrievals can be covered by insurance. 
• Louisiana: Providers cannot deny coverage for the diagnosis and treatment of correctable medical conditions solely because they result in infertility. Coverage excludes infertility medication, IVF, and other assisted reproduction procedures. 
• Maryland: Group plans of at least 50 participants offer coverage for various infertility treatment procedures, but more expensive ones are covered only after less expensive procedures have been attempted unsuccessfully. In addition, providers may impose a lifetime maximum benefit of $100,000 and three IVF cycles per live birth. 
• Massachusetts: Insurance providers cover medically necessary tests and procedures for infertility diagnosis and treatment, including IUI, IVF, GIFT, and ZIFT.
• Montana: Only health maintenance organizations (HMOs) are required to provide coverage for infertility services as part of basic preventive healthcare services. The extent of this coverage is not defined. 
• New Jersey: Coverage is provided for IUI, IVF, GIFT, ZIFT, and other infertility treatments if less expensive options have been attempted unsuccessfully. The coverage extends to no more than four egg retrievals. 
• New York: Providers cannot deny coverage for the diagnosis and treatment of correctable medical conditions solely because they result in infertility. Coverage excludes infertility medication, IVF, GIFT, ZIFT, and other procedures. 
• Ohio: Only HMOs are required to provide coverage for infertility services as part of basic preventive healthcare services but only when the procedure is medically necessary. The extent of this coverage is not defined. 
• Rhode Island: Insurance providers cover the diagnosis and treatment of infertility if the procedure is deemed medically necessary.
• Texas: Some insurance plans cover IVF if no other methods have worked and the couple are using their own eggs and sperm. 
• West Virginia: Only HMOs are required to provide coverage for infertility services as part of basic preventive healthcare services but only when the procedure is medically necessary. The extent of this coverage is not defined.

Note that even if insurance providers are not required to cover infertility treatment, some of them still do. For example, my state legislature does not obligate insurers to provide coverage for IVF or other assisted reproduction procedures, but my insurance plan offers a lifetime coverage of $25,000 nevertheless, after certain conditions are met (e.g., more than a year of failing to achieve pregnancy for those who are over 35, three unsuccessful IUIs before an IVF is attempted, etc.).

Although most health insurance providers do not cover infertility treatments if they are not required to do so, keep in mind that parts of these treatments (e.g., ultrasound imaging and blood tests) can be considered routine tests and thus at least partially covered by the insurer. The same is true for generic medication (e.g., clomiphene citrate). Still, the unfortunate reality is that many couples in the United States find themselves required to pay in full for their infertility treatments, and they have to be able to pay the entire amount up front.