Massachusetts Infertility & IVF Health Insurance Coverage

Massachusetts infertility and IVF health insurance is mandated by state law.

The Massachusetts infertility law mandates that general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits, also provide coverage for diagnosis and treatment of infertility, including in vitro fertilization (IVF).

Find out who this law applies to, what is covered, where the holes are, and how to protect your pregnancy.  

The Massachusetts infertility insurance mandate applies more broadly and with fewer holes than in other states. The infertility mandate applies to "all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth".

The key consideration is whether your health plan provides pregnancy benefits. Confirm coverage with your employer before beginning infertility treatments.

Some Massachusetts insurers deny infertility coverage if the female partner smokes, not providing coverage unless the woman undergoes a smoking cessation program, followed by a urine test to detect nicotine in the body.

The Massachusetts mandate updated the definition of inferitlity in 2010.

"Infertility' shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35.

For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable.”

The Massachusetts Infertility and IVF Insurance mandate stipulates that all insurers shall provide benefits for non-experimental infertility procedures including:

• Artificial insemination
• In Vitro Fertilization (IVF) and embryo placement (IVF - EP)
• Gamete Intra fallopian Transfer (GIFT)
• Intracytoplasmic Sperm Injection (ICSI)
• Zygote Intrafallopian Transfer (ZIFT)

Prescription infertility drugs are to be covered to the same extent as drugs for other medical conditions.

The Massachusetts infertility insurance law specifically excludes health care plans from having to cover:

• Experimental infertility treatments
• Surrogacy
• Reversal of voluntary sterilizations
• Cryopreservation of eggs

The Massachusetts infertility insurance law requires that certain infertility treatments be covered, but it does not stipulate the level of coverage.  Every insurance plan leaves you with some level of unreimbursed expenses.  Things like co-pays, co-insurance, and out of network charges can add up very quickly.  For example:

• Some prescription drug plans provide 50% reimbursement.  The other 50% of your fertility drug costs are yours.
• Co-insurance, the amount of allowed charges that are your responsibility may run to 20% to 30%.
• Out of network fees may come into play if your fertility clinic of choice is not in network with your plan.  You will be responsible for the amounts over and above what the insurance company reimburses as usual customary and reasonable.

Cut your infertility treatment costs by 1/3 or more by using your flexible spending account to pay for un-reimbursed infertility treatment expenses.

You may find that your employer does offer health insurance with infertility coverage.  And even if they do, you may find that you still have many left over bills. Be sure to take full advantage of our cost saving opportunities, and fund your maternity leave by purchasing supplemental health insurance before getting pregnant.