Does my plan cover infertility treatments?

When it comes to fertility treatments, that answer depends on where you live. There are 15 states that require health insurance providers to cover fertility treatments:

1. Arkansas

2. California

3. Connecticut

4. Hawaii

5. Illinois

6. Louisiana

7. Maryland

8. Massachusetts

9. Montana

10. New Jersey

11. New York

12. Ohio

13. Rhode Island

14. Texas

15. West Virginia

 

But these states are just mandated to offer some coverage, meaning that how much help you’ll actually receive varies. The type of fertility treatment coverage that insurance companies offer fall into the following categories:

- No coverage

- Coverage for infertility diagnosis

- Coverage for infertility diagnosis with limited treatment

- Coverage of medications

- Full infertility insurance coverage

 

Here is a detailed breakdown of the specific treatments each state covers.

 

Mandatory States

Couples living in one of the fifteen states with an infertility mandate have no guarantee of coverage. In addition to the many exclusions noted above, each requirement has unique wrinkles that determine who does or does not win this crazy and confusing lottery.

• The state where the issuing company writes the policy determines if the legal directive applies. The industry defines this as the “In Situs” jurisdiction. A group plan written (Sitused) in a non-mandate jurisdiction does not have to offer infertility benefits to employees living or working elsewhere.
• Both California and Texas have mandates to offer. The means that the issuing carriers must offer at least one group plan with the required benefit. Employer groups can purchase a policy with a fertility rider, or one without the rider.
• Group and individual markets have different requirements. Some directives apply only to large groups (25 or 50 plus more employees), while others include groups of 2 or more employees.
• Plan design is also a factor. Some mandates pertain only to Health Maintenance Organizations (HMO). Residents in a Preferred Provider Organization (PPO) design do not qualify.

State	Infertility	IVF	Market
Arkansas	No	Yes	Ind & Group
California	Yes	No	Group
Connecticut	Yes	Yes	Ind & Group
Hawaii	No	Yes	Ind & Group
Illinois	Yes	Yes	Group 25+
Louisiana	Yes	No	Ind & Group
Maryland	No	Yes	Ind & Group 50+
Massachusetts	Yes	Yes	Ind & Group
Montana	Yes	No	HMO
New Jersey	Yes	Yes	Groups 50+
New York	Yes	No	Ind & Group
Ohio	Yes	No	HMO
Rhode Island	Yes	No	Ind & Group
Texas	No	Yes	Group
West Virginia	Yes	No	HMO

 

How to avoid surprise bills

Whether you have some coverage or full infertility insurance, it’s still important to ask your insurance provider and doctor(s) questions to avoid surprise bills. The more specific your questions, the better. For example, just because your insurance plan covers medications, that doesn’t necessarily mean that they’ll pay for the particular fertility drugs you’ll need.

 

Asking what drugs they cover beforehand will help you make an informed decision when choosing your health insurance plan. And you want to always make sure that any labs or specialists that you are referred to are in-network. This will keep your medical costs low as well.

 

Getting maternity coverage

Thanks to the Affordable Care Act, insurance plans are required to offer some coverage during your pregnancy. And health insurance plans can’t turn you down or overcharge you because you’re pregnant.

 

Plans must offer folic acid supplements, gestational diabetes screening, Rh incompatibility screening, breastfeeding support and counseling and more. But what specific services are covered and how much you’ll have to pay varies from plan to plan.