Many health insurance companies offer at least one plan covering infertility treatment, including the more expensive In Vitro Fertilization (IVF).

However, each company markets a variety of policies in the individual and employer-group market. Plus, sixteen states have legal mandates, and some employers have an incentive to be generous with their benefits. 

Precision is especially important when researching a complex topic with such high stakes attached to it.

Therefore, begin by learning about the main plan types and how the state mandates work on the policy level. Then move on to your issuing company’s policy document.

Health Insurance Plans

Couples should look at whether a specific health insurance plan covers infertility treatments such as In Vitro Fertilization. Issuing companies offer a variety of policy designs tailored to particular markets.

  • Supplemental: make claim payments directly to the insured and do not coordinate benefits with the primary program
  • Individual: non-group coverage obtained through the online marketplace or via a licensed agent
  • Group: employer-based healthcare acquired at work and paid via pre-tax payroll contributions

AFLAC

AFLAC and other brands offer supplemental health insurance that may cover infertility and IVF outcomes – but not the treatments themselves.  

Couples can enroll in AFLAC-type plans before conception and then file a claim for benefits when the artificial reproductive technology succeeds – when mom becomes pregnant and has a baby.

  • Replace lost income during unpaid maternity leave
  • Offset unreimbursed expenses from a hospital stay
  • Help with NICU costs after pre-term delivery

AFLAC is not the only entity offering supplemental programs.

Colonial Life

Unum

Prudential

Humana

Met Life

Mutual of Omaha

Individual

Finding individual health insurance plans that cover infertility treatments and IVF will prove challenging. Non-group markets lack the bargaining leverage needed to include benefits for artificial reproductive technologies. However, some state mandates (see below) may apply to specific designs.

  • Home Maintenance Organizations (HMO) may extend fertility benefits outside of non-group markets in Ohio and West Virginia
  • Preferred Provider Organizations (PPO) include benefits only when a mandate requires personal coverage across all designs

However, forwarding-thinking couples can optimize their design for the intended treatment result: mom’s pregnancy and childbirth. Request a quote for an individual plan with a smaller deductible and broader network of participating perinatologists and Neonatal Intensive Care Units (NICU).

Group

Group health insurance plans through employers are often the ideal place to look for IVF and infertility treatment coverage. The state mandates that do exist (see below) focus their requirements on the group marketplace – with notable oddities.

  • Self-insured employers are exempt from state requirements but must follow federal rules
  • Religious employers often object to supporting assisted reproductive because of embryo destruction and other reasons
  • The headquarter (situs) state of the employer often determines which mandate applies to nationwide groups

Also, many employers offer insurance plans that cover fertility voluntarily – so they can attract and retain a competitive workforce. For example, Starbucks, Cisco, Microsoft, and Mass Mutual differentiate their benefits this way.[1]

Perhaps it is time to update your resume, or apply for financing.

Tricare

Tricare is a healthcare program managed by the Defense Health Agency under the leadership of the Assistant Secretary of Defense. Tricare covers a range of first-line infertility treatments for most uniformed service members, retirees, and their families. However, only those injured in the line of duty qualify for coverage of advanced artificial reproductive technologies such as IVF.[2]

Tricare pays for medically necessary services combined with a natural conception for all of its member population.

  • Treatment of reproductive system illnesses and injuries
  • Care for erectile dysfunction
  • Other diagnostic services

Tricare members injured in the line of duty may have coverage for additional therapies that typically cost more.

  • Sperm retrieval
  • Egg retrieval
  • In vitro fertilization (IVF)
  • Artificial insemination
  • Blastocyst implantation
  • Cryopreservation and storage of embryos

Tricare will never pay for surrogacy or fertility preservation (egg or sperm freezing) regardless of any wounds or disabilities acquired while on active duty.

Medicare

Medicare is a government-run health insurance program for senior citizens over the age of 65, younger people receiving social security disability (SSDI), and patients with end-stage renal disease.

As a government-issued plan, Medicare does not have to comply with any of the fifteen state mandates. Therefore, Medicare will not cover any form of infertility treatment, especially not IVF.[3]

  • Part A pays for inpatient hospital stays
  • Part B pays for doctors’ services, outpatient care, medical supplies
  • Part D pays for prescription drugs

Covering States

Researching the states that cover infertility treatments and or In Vitro Fertilization is a good starting point. However, you must dig much more in-depth because the laws include an unexpected twist, lots of exclusions, and unique rules for individual and group plans.

First, we explain the twist. The legal mandates for coverage pertain only to policies issued in the state (not the companies behind them).

  • Employer group plans issued in a mandate state apply to employees across the country
  • Group policies issued in non-mandate states may deny the extra benefits to employees living in mandate states

Exclusions

The states with laws requiring infertility and or IVF health insurance coverage also have many exclusions. Some of these prohibitions are universal, while others pertain only to plans issued in one or two states.

  • All exclude benefits after voluntary sterilization such as tubal ligation or vasectomy
  • Many limit IVF benefits to when the husband’s sperm fertilizes the wife’s eggs, limiting several services and patient groups
  • Homosexual couples face an additional exclusion via a standard definition, “inability to become pregnant through sexual intercourse.”
  • No regulations support payment for Preimplantation Genetic Diagnosis (PGD) with IVF as it is classified as experimental
  • Many states deny coverage for surrogacy – especially for the pregnancy and delivery of the surrogate

Mandates

Couples living in one of the fifteen mandate states have no guarantees of infertility treatment of IVF coverage. In addition to the rules and exclusions noted above come two more anomalies.

  • “Mandates to offer” in California and Texas mean that a company operating in the state must offer at least one plan with the specific benefits. However, groups are not required to purchase the compliant design for their employees.
  • Group and individual markets have different requirements. Some directives apply only to large groups (25 or 50 plus more employees), while others include those with two or more workers.

State

Infertility

IVF

Market

Arkansas

 

X

Ind & Group

California

X

 

Group

Connecticut

X

X

Ind & Group

Hawaii

 

X

Ind & Group

Illinois

X

X

Group 25+

Louisiana

X

 

Ind & Group

Maryland

 

X

Ind & Group 50+

Massachusetts

X

X

Ind & Group

Montana

X

 

HMO

New Jersey

X

X

Groups 50+

New York

X

 

Ind & Group

Ohio

X

 

HMO

Rhode Island

X

 

Ind & Group

Texas

 

X

Group

West Virginia

X

 

HMO

Health Insurance Companies

Couples asking whether a particular health insurance company covers In Vitro Fertilization and other infertility treatments need to be far more specific. Remember that the plan – not the organization behind it – determines what benefits you are eligible to receive.[4]

  • People who already have coverage through a particular company should consult their policy document, which spells out the benefits – this resource is the ultimate authority
  • Those looking to change should research the employee benefits offerings of each spouse by communicating with the human resources department because state mandates apply mainly to groups
  • Searching online by organization name leads you down a rabbit-hole of forum posts with inaccurate anecdotal answers

Not Cover

Consider that health insurance companies are reluctant to cover IVF and other infertility treatments because doing so would drive premiums higher for all members. Most people shop for healthcare based on price and do not need artificial reproductive technologies, which boosts medical expenses in three areas.

  1. Average IVF cycle cost of $15,000
  2. Resulting pregnancies are high-risk
  3. Pre-term infants require NICU confinement

Also, most of these services are often not medically necessary. They do not treat an illness, injury, condition, disease, or its symptoms. The inability to conceive does not pose a health risk.

BCBS

Blue Cross Blue Shield (BCBS) will sometimes issue plans that cover infertility treatment, including IVF, when required by state law or when requested by an employer group.

However, Blue Cross Blue Shield is a national federation of affiliated companies using this trade name. BCBS is thirty-six different independently operating local organizations rather than one – and they often use alternate corporate names.[5]

  • Anthem BCBS
  • Empire BCBS
  • Highmark BCBS
  • Horizon BCBS
  • Regence BCBS

Therefore, couples must identify the policy document associated with the specific BCBS entity that issues the coverage. One name is far too broad of a query.

Aetna

Aetna is a health insurance company operating in all fifty states with plans in the individual and group marketplaces. Aetna policies cover infertility treatments and IVF when legally required or when employers request extra benefits.

For example, the corporate website includes this disclaimer, which confirms this point: [6]

Aetna covers diagnostic infertility services to determine the cause of infertility and treatment only when specific coverage is provided under the terms of a member’s benefits plan. All coverage is subject to the terms and conditions of the plan.”

Cigna

Cigna is a health insurance company operating in ten total and three mandate states with plans in the employer group and individual markets. Therefore, some Cigna policies will cover infertility services – including IVF – and many more will not.

Once again, the Cigna corporate website includes several disclaimers illustrating the main point of this article.[7]

  • ”Coverage of infertility diagnostic and treatment services varies across plans. Refer to the customer’s benefit plan document for coverage details.”
  • “In addition, coverage for some infertility-related services, including certain fertility preservation services may be required by state mandates.”

United HealthCare

United Health Care is a nationwide insurance company offering policies in the individual and employer group markets. Operating in all fifty states, United Health Care must comply with fifteen different mandates.

Yet another time, the United Health Care corporate website publishes a document with disclaimers supporting our central premise.

  • Check the member specific benefit plan document for inclusion or exclusion. Some states mandate benefit coverage for Infertility services. Refer to state mandates.”
  • “When the member’s plan does not include benefits for Infertility, the following services are not covered:
    • All health care services and related expenses for infertility treatments, including Assisted Reproductive Technology, regardless of the reason for the treatment
    • In vitro fertilization regardless of the reason for treatment
    • Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue, and ovarian tissue.

[1] Employee Benefit News

[2] Tricare Assisted Reproductive Services

[3] Medicare Test, Item, Service

[4] National Conference of State Legislators

[5] Blue Cross Association

[6] Aetna Clinical Policy Bulletin

[7] Cigna Medical Coverage Policy