States Laws & Coverage for Fertility Treatments & Medication
People who are affected by infertility do have options to try, but in vitro fertilization (IVF) and the 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.
On a global scale, 15% of reproductive-aged couples are impacted by infertility around the world, 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. Depending on the treatment, 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, we’ll explain how state laws affect insurance coverage for fertility treatment in more detail.
- Mandatory insurance coverage for fertility treatment and medication is not widespread in the U.S.
- 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 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).
- 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.
- In vitro fertilization (IVF): IVF is a type of assisted reproductive technology that involves fertilization of an egg 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
Fifteen states require private insurance coverage for fertility treatment, according to the Kaiser Family Foundation. They include:
- Arkansas: requires individual and group insurers to provide coverage but not HMOs and self-insurers.
- Connecticut: mandates all health insurers provide coverage. Religious employers and self-insurers are exempt. Additionally, people need to be on the plan for more than 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 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.
- Maryland: requires coverage with some exceptions: employers with fewer than 50 employees, religious employers and self-insurers.
- Massachusetts: law excludes self-insurers from the coverage requirement.
- Montana: requires HMOs to cover fertility treatment.
- New Hampshire: exemptions to its requirements are slightly different than other states. Self-insurers are exempt, as well as extended transition to ACA-programs and the Small Business Health Options (SHOP) program.
- New Jersey: law includes an exemption for employers with fewer than 50 employees, religious employers and self-insurers.
- New York: law 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 coverage; self-insurers are exempt.
- Rhode Island: law requires insurers, including HMOs, to provide coverage, but self-insurers are exempt.
- Utah: law, as in other states, does not require self-insurers to provide fertility treatment coverage.
- West Virginia: only requires HMOs to provide fertility treatment coverage.
California and Texas have laws that require insurance companies to offer coverage, but employers do not have to select insurance plans with that coverage. States may also have age limits on eligibility.
Factors that Affect Insurance Coverage of Fertility Treatments
Infertility is typically defined as the inability to conceive after one year of unprotected, heterosexual sex. Insurance companies often uses 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 play a role in whether or not you can access coverage for fertility treatment. Many 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.
More large employers are opting to offer this kind of coverage. In 2015, 36% of companies with 20,000 or more employees offered coverage for IVF. In 2020, that number grew to 42%.
If you have health insurance through the exchange, 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 could make it easier for LGBTQ people to access fertility treatment.
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 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 you live in, your insurance company, and your employer.
How Much do Fertility Treatments Cost?
The average cost of a single cycle of IVF is about $12,400, according to the American Society of Reproductive Medicine. Many people need multiple rounds of IVF before becoming pregnant. The cost of fertility treatments depends on where you live, your provider, your insurance, the type of treatment, 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?
Fifteen states require private insurers to cover fertility treatment. The amount of coverage and type of insurers required to offer coverage differs 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.