Infertility Treatment & In Vitro Fertilization - IVF - Insurance Coverage Issues
Health insurance coverage for infertility and IVF treatments overview
Medical insurance coverage for infertility treatment and for IVF, in vitro fertilization can be straightforward or complicated. This is an effort to explain some of the issues regarding health insurance coverage for infertility testing and treatment.
Because our fertility clinic is in northern Illinois and close to Wisconsin – insurance coverage for IVF and infertility in Illinois and Wisconsin will be specifically addressed. Insurance coverage for infertility, artificial inseminations and in vitro fertilization varies greatly. Some insurance plans will cover no infertility services, some pay for all of it and many are somewhere in between.
About 15 states have some type of mandate for infertility insurance coverage – so couples in those states will be likely to get some help with payment for their fertility services from their health insurance plan.
In states without any infertility coverage mandate, most insurance plans do not help much with payment for fertility and IVF services. IVF insurance coverage is less common than coverage for fertility services other than IVF. This is because IVF costs more than other infertility testing and treatments.
Insurance plans in which we are currently “participating providers”
We can see patients with any PPO plan. When a doctor is “out of network” it does not mean that the insurance company will not pay for the services. If we are not “in network” with the plan, then the patient will usually have a higher amount of “coinsurance” (what they are expected to pay) as compared to if they went to a doctor that is “in network”.
We have many patients that see us “out of network”. They have decided to come to us “out of network” (and pay more out-of-pocket) because of our superior success rates, our personalized care, recommendations from friends or their doctor, or for other reasons.
We are currently “in network”
with these insurance plans
|Blue Choice (also Blue Options)||PPO|
(formerly United Resources Network)
Infertility testing and health insurance coverage
Health insurance plans will commonly (but not always) pay for services related to testing for infertility. However, many plans say that once the diagnosis has been established that they will no longer pay for fertility related services. This is likely due to the fact that covering diagnostic testing does not cost them very much.
There are potential gray areas with coverage for tests. For example, a woman is trying to get pregnant and has heavy periods and very bad menstrual cramps. She has a hysteroscopy at the fertility clinic to investigate the situation. Regardless of the findings of the test, the insurance company might pay for it in full – or reject payment saying that they don’t cover infertility. Was the test done for her bleeding and pain, or was it done for infertility? What if it was done for all of those reasons? It can be a little complicated and confusing at times.
Infertility treatment and insurance
Treatment for infertility is covered by insurance much less commonly than testing is. Outside of a state mandated situation (see below), when there is coverage for infertility treatment, it is fairly common to exclude IVF or to have a lifetime maximum benefit.
We commonly see health insurance plans that have between $10,000 and $25,000 as a lifetime max. This caps the potential costs for the insurance carrier. In other cases, insurance will cover testing and treatment up to and including intrauterine inseminations – but they will not cover IVF – in vitro fertilization services. Sometimes the “monitoring” of the IVF ovarian stimulation (blood and ultrasound tests) are covered, but all of the (more expensive) IVF codes are not covered.
State insurance mandates for infertility and IVF services
There are currently 15 states that have infertility mandates of some kind. The mandates are very different in terms of what is covered – how many IVF cycles, etc. Some of the mandates are very comprehensive and others much less so. Details of mandates other than Illinois are not discussed here.
States with some kind of infertility coverage mandate
State of Illinois insurance mandate for infertility and IVF services
The state of Illinois passed the Family Building Act in 1991. In short, it requires group health insurance plans that cover more than 25 employees to cover diagnosis and treatment of infertility up to and including 4 IVF attempts (egg retrieval procedures).
The text below is from the IL Department of
|Text of the Illinois Infertility Law (215 ILCS 5/356m)|
Sec. 356m. Infertility coverage.
(a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy related benefits may be issued, amended, delivered, or renewed in this State after the effective date of this amendatory Act of 1991 unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.
(b) The coverage required under subsection (a) is subject to the following conditions:
(1) Coverage for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:
(A) The covered individual has been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
(B) the covered individual has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
(C) the procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
(2) the procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.
(c) For purpose of this Section, “infertility” means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
(Source: P.A. 89-669, effective 1-1-97.)
More details about the Illinois infertility and IVF insurance mandate are available – click below for a PDF document from the State of IL:
Insurance Coverage Mandate Law for Infertility Treatment in Illinois
Loopholes in the Illinois infertility insurance mandate
It might seem that a mandate should be a mandate. However, in the case of Illinois, someone has decided that the IL mandate is “somewhat optional” (my own take on the situation). It has evolved over the years since 1991 so that now (2015) there seem to be some loopholes that allow employers to offer plans without infertility coverage.
This situation exists even though the law itself has not been repealed or changed. What has changed, perhaps, is interpretation and enforcement of the existing “infertility mandate”.
Common reasons we hear regarding why various plans in IL do not cover infertility services at all – or they do not live up to the full IL mandate include:
We have a self insured plan, so we don’t have to cover infertility
Our company is based in ________ (fill in the blank, Germany, Arizona, etc.)
Our insurance company is based in ________ (wherever)
It’s not our fault (the employer), we don’t know why that insurance company isn’t covering infertility
What all of these excuses come down to is – “we don’t want to pay for it, so sue us if you think that you can win”. Of course they don’t say that, but it’s still the bottom line. People don’t want to take on an expensive and possibly losing lawsuit against their employer – so they pay for their fertility services “out of pocket”.
Fortunately, many employers in IL are following the mandate and offer plans that cover the mandated infertility services. However, quite a few do not cover it – or only offer some coverage that falls short of the levels spelled out in the mandate.
Over time, more states are passing mandates for infertility insurance coverage. Who knows how the situation in Illinois will evolve over time. Infertility support organizations have also been lobbying for a national infertility insurance mandate – so far without success.
In many countries in the world infertility is considered to be a disease like any other – and covered by health insurance or the socialized medical system like any other disease would be. In the US it is looked at by insurance carriers more as a social issue rather than a medical issue – and then can be added to health insurance plans as an “extra”, if desired. In the end money drives it all.
State of Wisconsin infertility and IVF insurance coverage
Because our Gurnee office is close to the Wisconsin border we have many couples that come down to us for IVF treatment. Unfortunately, Wisconsin does not yet have any state mandate for infertility or IVF services to be covered. Some employers will cover it to some extent, but many provide no coverage at all.
It is fairly common for our Wisconsin patients to have some coverage for diagnostic testing, and much less common to have any coverage for treatment of infertility. About 5% of our patients from Wisconsin have insurance coverage for IVF. Hopefully, health insurance coverage for infertility and IVF in WI will become more common in the future.