When you pay for health insurance, you expect that your medical problems will be covered. Infertility patients often discover that fertility diagnosis and treatment are excluded from their medical insurance policy. Because infertility is not life threatening and having children is considered optional by some, medical care for infertility is often classified with other noncovered medical procedures such as cosmetic surgery and liposuction. Insurance coverage for infertility varies by the state, employer and size of company. In lieu of traditional insurance, some infertility patients have used nontraditional insurance programs called shared risk programs.
State Mandated Infertility Coverage
States regulate insurance coverage for medical conditions, and currently, only 15 states require that insurance companies and employers cover infertility diagnosis and treatment. Currently the list of states with mandated insurance coverage includes Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia. The actual details of how fertility insurance is provided varies dramatically among each of these states. Some of the common restrictions that limit coverage include requiring patients to be young (under 40 years old), to have a documented period of months or years of infertility and to adhere to arbitrary limits on the number of allowed treatment attempts or type of treatment attempts. Some states will not provide infertility coverage to single women or same-sex couples.
Employers and Infertility Coverage
Even in mandated states, the Federal Employee Retirement Income and Security Act (ERISA) passed in 1974, exempts employers who self-insure from state mandates, including the mandate to offer infertility coverage. In the United States, 9 million federal employees, retirees and dependents have their insurance coverage through the Federal Employee Health Benefits Program (FEHBP), which is also exempted from any state mandate to cover infertility. In nonmandated states, employers may opt to include infertility insurance for their employees, but this option typically costs more than the basic plan offered to employees.
How to Tell if Your Policy Covers Infertility Treatments
If your insurance plan does not explicitly exclude infertility coverage in the contract with your employer, it should be covered, but you still may have to fight for it. The summary of benefits that you receive from human resources (HR) at enrollment time may not include all the coverage you have. Ask your HR department to give you a copy of the actual contract between the insurance company and your employer that details employee coverage. Under ERISA, your employer must give you a copy of the contract, not just the summary of benefits.
Typically, insurance policies deny coverage for infertility for three reasons: infertility is not a disease, infertility treatment is not medically necessary, or infertility treatments are experimental. These three reasons are not valid and can be appealed. You and your physician should both write a letter appealing the denial. Your physician can explain why the treatment is medically necessary and that the American Medical Association no longer defines infertility treatments as experimental.
Legal Support for Infertility Insurance Coverage
Most employees are not willing or able to sue their employer or their insurance company for infertility coverage due to costs of litigation and fear of reprisals. However, some legal arguments have been successful in pushing forward the idea that infertility coverage should be covered although case law in this area is not settled.
Under the American Disability Act (ADA) passed in 1991, companies who employ at least 15 employees are prohibited from discriminating against their employees on the basis of a medical disability. Attorneys have successfully argued that infertility is a disability under this act because it is a medical condition of the reproductive system and interferes with a major life activity (procreation).
The Equal Employment Opportunity Commission (EEOC) has published financial guidelines requiring insurers to show it is financially prohibitive to offer insurance coverage for a particular medical condition in order to escape the ADA requirement. Because some studies have shown that infertility coverage can be added for less than $2 per month per family, the "too expensive to offer" guideline can not be met.
You Nave No Infertility Coverage; Now What?
Don't panic. Your insurance coverage may not pay for fertility per se, but some parts of your care may still be covered. For instance, your medical drug coverage may not exclude the use of ovarian stimulation medications. Sometimes, physician fees are covered, but technical procedures are not, or alternatively, the opposite is true. If you do have to pay everything out of pocket, you will be able to deduct these expenses as medical expenses on your tax return. Also, if your employer has a medical spending plan, you can put aside pretax dollars to pay for infertility treatments, which reduces your tax liability.
Shared Risk Programs
If you need assisted reproductive technology (ART) procedures like in vitro fertilization, your fertility clinic may have a shared risk program, which is a kind of insurance coverage. For a set payment, you receive a certain number of prepaid ART cycles (usually three). The costs of diagnosis and stimulation drugs are usually not included in the prepaid program. The cost is usually more than a single treatment cycle but less than three cycles. So if you get pregnant on the first try, you've paid too much, but if it takes three tries, you have some of your care for free. If you fail to get pregnant, you are refunded 90 to 100 percent of your prepaid fee. Shared risk programs are controversial because like traditional insurance, patients who qualify for the program sometimes have a better than average prognosis, making it more likely that the clinic won't need three tries to achieve pregnancy.
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