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:
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.
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.
|Arkansas||No||Yes||Ind & Group|
|Connecticut||Yes||Yes||Ind & Group|
|Hawaii||No||Yes||Ind & Group|
|Louisiana||Yes||No||Ind & Group|
|Maryland||No||Yes||Ind & Group 50+|
|Massachusetts||Yes||Yes||Ind & Group|
|New Jersey||Yes||Yes||Groups 50+|
|New York||Yes||No||Ind & Group|
|Rhode Island||Yes||No||Ind & Group|
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.