Infertility is a devastating blow. You may grieve your fertility just as you would grieve any other loss, or grieve for the child you wish you could have had long ago. Infertility treatment is highly effective, yet about half of infertile couples do not seek treatment. For many, fears of exorbitant costs are a major deterrent.

Most people have heard that insurance does not cover infertility treatment. The truth is more complicated. Texas has an insurance coverage mandate that requires insurance plans to offer IVF coverage. Even if you don’t have IVF coverage, however, you may have some level of infertility coverage available to you.

Don’t let cost deter you from seeking the help you need. Infertility treatment can be surprisingly affordable, and may even be covered by insurance. You won’t know exactly which treatments you need and whether they are covered by insurance until you seek expert help. So a fertility specialist is your most important ally as you struggle to get pregnant. Don’t let fear of costs prevent you from having a child.

Coverage for Basic Health Care and Medically Necessary Treatment

Much of infertility care falls under the umbrella of basic health care. That’s because many conditions that affect fertility also affect overall health. For example, polycystic ovary syndrome may cause excessive body hair growth and insulin resistance. Certain STDs and infections can cause both pelvic inflammatory disorder and infertility, and a varicocele in men may cause pain and other problems.

Some examples of what insurance may cover as medically necessary include:

• Physical exams to assess reproductive health issues.
• Some blood work, especially if testing for infections or chronic health problems.
• Imaging scans if a suspected health issue is the culprit -- such as a damaged fallopian tube.

You may find that insurance covers some components of treatment, but not others. This can greatly reduce costs, even if you still have to pay some money out of pocket. Some insurers attempt to reject claims for any infertility services at all. For example, an insurer might reject treatment for endometriosis if the person seeking treatment is doing so because of infertility. Understanding exactly what your plan covers and does not cover is key to maximizing your benefits and getting help funding treatment.

How your doctor bills insurance is key to getting coverage as well. Many gynecologists and other providers bill any and all testing as fertility-related if your underlying motivation is the desire to get pregnant. A fertility specialist, however, knows how to correctly bill insurance to maximize benefits. Fertility specialists have worked with numerous insurers, and have a keen understanding of what each insurer will and will not cover. This means they can bill more intelligently, and give you a more reliable estimate of what will and will not be covered.  

Fertility Insurance Rules in Texas

Texas is one of just 16 states to have enacted an insurance mandate requiring some infertility treatment coverage. Unfortunately, among these 16 states, Texas’s law is one of the weakest. Texas requires insurers to offer coverage for in vitro fertilization (IVF). It does not require employers to pay for this coverage or insured people to buy it.

This means that you have the option to buy a plan that covers IVF, but that plan will likely cost more. For people who do not struggle with infertility, this cost can be a deterrent. Or maybe you didn’t opt for IVF coverage when you first purchased your plan, and are having trouble getting it now.

Consumer choice and individual plans are not required to cover IVF. Texans are also increasingly investing in non-insurance plans, such as Christian cost-sharing plans. These plans are not required to cover IVF and rarely do.

Additionally, religious employers -- such as Christian universities, closely held religious corporations, and churches -- are not required to offer plans that provide coverage for IVF. They are not prohibited from doing so either, though, so the fact that you work for a religious employer does not necessarily mean you don’t have coverage. Self-insured employers are also not required to offer IVF.

Plans that do cover IVF are not required to cover first-line infertility treatments. These treatments tend to be more affordable and work well for many conditions. First-line treatments directly treat a specific fertility issue. For example, ovulation induction is a treatment for PCOS and some other ovulatory disorders.

If you are planning to have a baby in the next few years, or if you have already begun trying for a baby, consider investing in a plan that covers IVF. IVF can cost several thousand dollars, and many couples need to try multiple cycles. So the small additional premium will still offer significant cost savings beyond the significant expense of IVF infertility treatment.

Insurance Coverage in Other States

While most of our patients have insurance coverage in Texas, some travel to Texas from other states. Additionally some Texas residents may be insured in other states. This can happen if you work remotely for a large company, if your company bought insurance coverage in another state, or if you’ve recently moved. So it’s important not to assume that your insurance coverage is in Texas. Check your policy. The state law that governs your policy may influence which services you are eligible for.

Some examples of laws in other states include:

• California requires insurers to offer the chance to buy infertility coverage. This coverage must cover most infertility treatments, but not IVF.
• Rhode Island requires plans that offer maternity coverage to also cover medically necessary fertility procedures.
• Ohio requires coverage for most diagnostic and exploratory infertility services.
• Louisiana prohibits exclusion of coverage for a correctable medical condition solely because that condition also causes infertility.

Most states, however, do not mandate any coverage at all.

Employers increasingly understand that fertility can be key to worker happiness, and therefore to productivity. So some large employers now offer health insurance packages that feature some form of infertility coverage even when and where state laws do not require it.

Examples of employers that cover some infertility treatments include:

• Bank of America
• Spotify
• Newscorp
• Johnson & Johnson
• Sales Force
• Boston Consulting
• Conair

Qualifying for IVF Insurance Coverage

If you have a plan that covers IVF, you still have to qualify for treatment. Each plan sets its own standards. If you have an out-of-state plan or you receive coverage above and beyond that required by the law, the legal mandate in Texas may not apply to you. Instead, you’ll need to review your policy to qualify. Your fertility specialist can help you with this.

If you’re in Texas and have purchased a plan that meets the state’s minimum requirements for IVF coverage, here are the qualifying criteria:

• You must have had infertility for at least five continuous years. Seeking treatment as early as possible can help you document this history.
• You must have tried less costly treatments such as ovulation induction.

In certain cases, couples with any of the following conditions are eligible for treatment without the five-year waiting period:

• Diethylstilbestrol (DES) exposure
• Removal or blockage of one or both fallopian tubes
• A man who does not produce sperm
• Endometriosis

Note that the diagnostic procedures for some of these conditions are likely to be covered by insurance. Endometriosis, for example, is a serious and chronic medical condition, and insurers typically cover both diagnostic testing and treatment.

Other Options for Affording Infertility Care

It’s a cruel reality that couples with more money have a better chance of getting pregnant. Money opens more treatment options and allows you to try longer without exhausting your resources. That doesn’t mean you have to be extremely wealthy to treat your infertility. A number of strategies can help slash costs or make treatment more affordable.

Talk to your doctor about:

• Lifestyle changes. Some fertility-related conditions respond well to lifestyle changes. If you have time to wait, taking a few months to fix various habits can work wonders. For example, many women with PCOS find that they are able to get pregnant by losing weight or by going on a low-sugar, low-carbohydrate diet.

• Fertility preservation. Freezing your eggs or sperm, if they are healthy, gives you time to try other strategies without worrying about running out your biological clock. If you’re in school or building your career, these fertility preservation strategies buy time until you have more money.
• A more conservative treatment approach. You can try every available treatment and test, or you can stick only to the tests more likely to work. Ask your doctor about the cheapest options, and then get details on how likely they are to succeed.
• Home fertility monitoring. Monitoring your cycles for a few months can reveal important data about your fertility. This may reduce the number of tests you need, and provide important diagnostic clues. Ask your doctor about how to monitor your fertility at home.
• Financing. The desire to have a child is the most fundamental human drive. Many fertility clinics offer financing or payment plans. You may also be able to put treatment on a credit card. Some credit cards offer no-interest introductory rates, so if you pay the card down within a year or two, you won’t accrue interest and finance charges.

Open communication with a fertility expert is key. Don’t rely on the Internet, a family physician, or friends and family to tell you what to do. When money is an issue, you need expert insight. A fertility specialist can help you get pregnant quicker, saving you time, money, and heartache.

When to See a Fertility Specialist

Couples concerned about infertility treatment costs often delay care. One recent analysis found that wealthy, educated, and older couples are more likely to seek treatment, suggesting that money plays a major role. Delaying treatment can actually drive up costs. That’s because fertility tends to decline with age. Moreover, some fertility issues get worse with time. For example, a person with an STD can expect that their fertility will continue to decline until they get treatment. In some cases, the damage can even become severe enough to be irreversible.

Let’s consider a common scenario: a woman with PCOS who may not ovulate or who only ovulates infrequently. She and her husband try for a year, then she tries some lifestyle remedies. These remedies help a little, and she begins ovulating every three months but still can’t get pregnant. She and her husband decide to try for another year. But by the end of that year, she’s 35 and not only dealing with the effects of PCOS but also age. If she had started earlier, treatment might have been a simple matter of ovulation induction or treating insulin resistance. Now, it’s more likely that she will need IVF. If she waits even longer, the odds of needing multiple IVF cycles increase. The costs steadily multiply over time.

Many infertile couples mistakenly believe they can minimize costs by seeking treatment from a gynecologist or family physician. Some opt for a few tests here, a few tests there, and hope they’re lucky enough to identify the cause. This is also a recipe for spending more in the long run. Fertility experts are experts in fertility care. They know about emerging research. They understand what works and what doesn’t. They can help you construct a treatment plan that’s consistent with your values and goals, and that helps you remain within your budget.

So when should you see a fertility specialist? If you’ve tried for longer than a year, had two or more miscarriages in a row, or the woman is over 35 and you’ve tried longer than six months, seek treatment. You should also seek treatment if you have a history of prior fertility issues or a condition known to compromise fertility. Women with irregular or no menstrual cycles should see a doctor before trying, as should couples in their forties.

The Center of Reproductive Medicine, in Houston, Texas, understands that infertility affects your finances, your body, your self-esteem, your family, and your relationship. We want you to know you are not alone. There is hope, and the sooner you seek treatment, the better your chances are. We’re here for you. We listen, empathize, and understand. Give us a call today!