States’ Laws and Insurance Coverage for Fertility Treatments and Medication

Fact checked by Vikki VelasquezFact checked by Vikki Velasquez

People who are affected by infertility have options to try, but in vitro fertilization (IVF) and diagnostics, medication, surgery, and other treatments can be expensive. In some cases, medical insurance will cover many of the costs, but in other cases, it won’t.

Around the world, 17.5% of reproductive-aged couples are impacted by infertility, according to World Health Organization (WHO) estimates. The majority of people affected by infertility (including men, women, LGBTQ couples, and single people), will pay out of pocket for treatment. Depending on the services received, out-of-pocket costs can easily reach thousands of dollars.

Some states have laws that require insurance companies to cover treatment for infertility, but the laws vary. Here is a detailed explanation of how state laws affect insurance coverage for fertility treatment.

Key Takeaways

• Mandatory insurance coverage for fertility treatment and medication is not widespread in the United States.
• Many insurers do not deem these healthcare services “medically necessary.”
• Fifteen states have laws that require specific private insurers to cover infertility treatment.     
• Same-sex couples often face higher barriers to accessing coverage for fertility treatment.

What’s Included With Fertility Treatment?

The type of fertility treatment that a doctor prescribes will depend on the needs of the individual or couple. Common fertility treatments include:

• Medication: Some medications, such as clomiphene citrate and letrozole, can help treat infertility in women by stimulating ovulation. Other medications may be prescribed in conjunction with fertility treatments, such as in vitro fertilization (IVF), mentioned above and described below.
• Intrauterine insemination: Intrauterine insemination, also known as artificial insemination, involves inserting sperm into the uterus. Occasionally, medications are also prescribed to help stimulate ovulation before the procedure.
• IVF: IVF is a type of assisted reproductive technology that involves fertilizing eggs outside of the uterus and moving embryos back to the uterus.
• Surgery: Surgical procedures such as laparoscopy and hysteroscopy may be indicated to diagnose infertility in women or address potential barriers to conception, such as endometriosis or uterine fibroids.

State Laws on Fertility Treatments

Seventeen states require private insurance coverage for fertility treatment, according to Resolve: The National Fertility Association and the Kaiser Family Foundation. They are:

• Arkansas requires individual and group insurers to provide coverage but not health maintenance organizations (HMOs) and self-insurers.
• Colorado requires all large group health plans with more than 100 employees to provide coverage. Religious employers and self-insurers are exempt.
• Connecticut mandates that all health insurers provide coverage. Religious employers and self-insurers are exempt. Additionally, people need to be on the plan for at least 12 months to be eligible.
• Delaware has a coverage mandate that excludes employers with fewer than 50 employees, religious employers, and self-insurers.
• Hawaii mandates that individual and group insurers provide coverage, but self-insurers are exempt.
• Illinois excludes employers with fewer than 25 employees, religious employers, and self-insurers from its laws.
• Maine began requiring all health plans to provide coverage on Jan. 1, 2024.
• Maryland requires coverage with some exceptions: employers with fewer than 50 employees, religious employers, and self-insurers.
• Massachusetts excludes self-insurers from the coverage requirement.
• Montana requires HMOs to cover fertility treatment. Religious employers and self-insurers are exempt.
• New Hampshire has exemptions to its requirements that are slightly different from other states. Extended transition to Affordable Care Act (ACA) policies and the Small Business Health Options Program (SHOP) are exempt.
• New Jersey includes an exemption for employers with fewer than 50 employees, religious employers, and self-insurers.
• New York does not require individual and small group markets to cover IVF, and self-insurers are exempt from the state’s coverage laws.
• Ohio requires HMOs to provide “medically necessary” infertility services, but IVF is not required by law; self-insurers are exempt.
• Rhode Island requires insurers, including HMOs, to provide coverage to women between the ages of 25 and 42; self-insurers are exempt.
• Utah, in a pilot program extended through 2024, requires the Public Employees’ Health Plan to provide coverage.
• West Virginia only requires HMOs to provide fertility treatment coverage; self-insurers are exempt.

Beginning in 2025, the District of Columbia will require all health insurers that offer an individual, small group, or large group health plan to provide coverage. Only employers that are self-ensured will be exempt.

Note

California and Texas have laws that require insurance companies to offer coverage—including IVF in Texas but not in California—but employers do not have to select insurance plans with that coverage. States also may have age limits on eligibility.

Factors That Affect Insurance Coverage of Fertility Treatments

Infertility is typically defined as the inability to conceive after 12 months or more of regular unprotected sex. Insurance companies often use a definition like this to determine when people can become eligible for fertility treatment coverage. Fertility insurance may cover a wide range of fertility treatment services or only a few services.

If you have insurance through your employer, the size of the company you work for plays a role in whether or not you can access coverage for fertility treatment. Several states that have laws requiring insurance companies to cover fertility treatment have exemptions for employers with fewer than 50 or fewer than 25 employees. Additionally, employers that self-fund their insurance are not required by state law to provide coverage for fertility treatment.

According to a survey by the International Foundation of Employee Benefit Plans, more U.S. employers are opting to offer this kind of coverage. In 2022, 30% of U.S. organizations offered coverage for IVF. In 2020, that number was 24%.

If you have health insurance through the Health Insurance Marketplace, keep in mind that the Affordable Care Act (ACA) does not require insurers to offer coverage for fertility treatment.

Much of the conversation around fertility treatment coverage focuses on heterosexual couples trying to have a child. But same-sex couples and single women also turn to fertility treatment when family planning, often facing more barriers to access. Discrimination lawsuits against major insurers and others could make it easier for LGBTQ people to access fertility treatment. Aetna, for example, agreed to cover IVF and other infertility treatments for all customers nationally, as part of a lawsuit settlement.

Ask your employer what kind of insurance plan it offers. An employer with a self-funded plan is not required to follow state insurance laws, which may mean that your plan does not offer coverage for fertility treatments.

Does Insurance Cover Fertility Treatment?

Whether or not your insurance will help pay for fertility treatment depends on several factors, including the state where you live, your insurance company, and your employer.

How Much Do Fertility Treatments Cost?

The average cost of a single cycle of in vitro fertilization (IVF) ranges from $15,000 to $20,000 or more. Many people need multiple rounds before becoming pregnant. The cost of fertility treatments depends on where you live, your provider, your insurance, the type of treatment you need, and the duration of treatment. Your insurance may cover the cost, but it may not. Only some state laws require that insurance coverage include fertility treatments.

How Many States Have Laws Requiring Some Kind of Insurance Coverage for Fertility Treatments?

Seventeen states require private insurers to cover fertility treatment. The amount of coverage and the type of insurers required to offer coverage differ from state to state.

How Does Your Employer Affect Your Insurance Coverage for Fertility Treatment?

If you have insurance through your employer, you will need to determine your coverage eligibility. In some states, companies with fewer than a certain number of employees are not mandated by state law to provide coverage. If your employer has a self-funded insurance plan, it will not be subject to the state laws requiring fertility treatment coverage.

What Kind of Additional Barriers to Fertility Treatment Do LGBTQ Couples and Individuals Face?

Same-sex couples and individuals often find it more difficult to receive insurance coverage for fertility treatment because they do not meet insurance companies’ definition of infertility. Insurers may require LGBTQ individuals to pay for several rounds of fertility treatment out of pocket before offering coverage.

The Bottom Line

Couples and individuals who decide to pursue fertility treatment may or may not have insurance coverage, depending on where they live and what kind of insurance they have. Whether paying out of pocket or with the assistance of insurance, you can expect that a fertility treatment will be a significant expense.

Read the original article on Investopedia.