Couples trying to conceive often ask what health insurance covers infertility or In Vitro Fertilization (IVF) treatment.

It is not an easy issue to address. The topic is complex and the rules are confusing and inconsistent.

Insurance will cover medically necessary procedures. Unfortunately, Assisted Reproductive Technologies (ART) does not meet the standard. However, many states mandate coverage in some form.

Purchasing Individual Plans Covering Treatment

Purchasing individual health insurance covering infertility and In Vitro Fertilization treatment is very difficult. Couples look to the individual market when their existing plan does not have the desired benefits. However, this approach rarely works.

The options to cover elective procedures are thin (assisted reproductive techniques). This is what most people want to find. The coverage for medically necessary steps is widely available, but few people have a qualifying condition.

Elective Procedures

Individual plans do not pay for any elective assisted reproductive treatments unless required by state law. Only 8 states have regulations pertaining to individual policies and these elective or optional protocols.

 Therefore, couples living in the 42 states without an individual mandate must identify an alternative. 

Pay for IVF without insurance by the book. Make a small upfront investment to save your family thousands later on.

  1. Find insurance directly covering related services
  2. Leverage the tax code to maximum advantage
  3. Borrow money to pay for treatments the right way
  4. Buy supplemental policies before your next cycle

Medically Necessary Conditions

Most individual health insurance plans will cover medically necessary infertility testing, diagnosis, and treatment with no waiting period. This holds true across the country.

  • Medical necessary means something like “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms.”
  • The Affordable Care Act requires coverage for pre-existing conditions with no waiting period.

Plans are likely to pay for medically necessary conditions with no waiting period. Below is a sample of common disorders that hinder conception and could fit in this category.

  • Sexually transmitted diseases often cause fallopian tube damage or blockage. Chlamydia and gonorrhea are quite common and can lead to pelvic inflammatory disease. Covered items include blood tests to isolate these bacteria and antibiotics.
  • Endometriosis causes painful menstrual cramps, digestive or gastrointestinal symptoms, and fatigue. Covered services for endometriosis may include the pelvic exam to search for cysts and scars, ultrasound to create images of cysts, pain medications, hormonal therapy, and conservative laparoscopic surgery.
  • Polycystic Ovarian Syndrome (PCOS) is a hormonal imbalance problem. PCOS causes weight gain, fatigue, unwanted hair growth, and can lead to diabetes and high blood pressure. Covered services for PCOS can include hormone therapy and smoking cessation programs – if applicable.
  • Uterine fibroids that impinge upon the endometrial cavity (submucosal) affect conception. Covered services for uterine fibroids may include hormones to regulate the menstrual cycle, non-invasive and traditional surgical procedures.
  • Thyroid problems such as Hyperthyroidism (overactive thyroid), and Hypothyroidism (underactive thyroid) can both prevent ovulation. Covered services may include diagnostic blood tests and drug therapies.

Assisted Reproductive Technologies

Finding and then buying individual health insurance plans covering a specific Assisted Reproductive Technology (ART) is very difficult. Carriers do not consider ART procedures as medically necessary. They do not affect a cure of an underlying disease or illnesses, relieve pain, or restore function. Only 8 states have individual mandates.

However, couples across the nation have plans covering one or more ART procedures. The next set of facts and the following two sections can help you develop a strategy.

  • An additional 7 states require group plans and/or Health Maintenance Organizations (HMO) to cover ART procedures. See the next section.
  • Group plans issued in mandate states must comply with the rules for members living in non-legal directive regions. See the section after that for coverage by employers.
  • The 15 laws often specifically include or exclude named ART procedures. Read each legal requirement carefully if the clinic recommends any of the following services.
    • Ovulation induction
    • Artificial insemination
    • Donor sperm, eggs, or embryos
    • In Vitro Fertilization (IVF)
    • Gamete intrafallopian transfer (GIFT)
    • Intracytoplasmic sperm injection (ICSI)
    • Preimplantation genetic diagnosis (PGD)
    • Surrogacy

State-by-State Coverage Infertility and IVF

Health insurance coverage for infertility or In Vitro Fertilization treatment often depends on the state where the patients live or work. Fifteen have mandates that require certain plans to pay for Assisted Reproductive Therapies (ART).

However, the legal directives work differently than many people expect. Couples trying to conceive should know the exclusions, participating states, and how the requirements project coverage across the USA.

Common Exclusions

Each mandate has unique rules regarding infertility insurance coverage. However, many rules apply the same way in every state – particularly when it comes to IVF.

  • All laws exclude coverage after a voluntary sterilization such as tubal ligation or vasectomy.
  • Many limit IVF coverage to when the husband’s sperm fertilizes the wife’s eggs. This common rule excludes patients in several categories.
  • Homosexual couples face an additional exclusion via a common definition, “inability to become pregnant through sexual intercourse.”
  • No regulations support payment for Preimplantation Genetic Diagnosis (PGD) with IVF. Carriers classify PGD testing as experimental.
  • Coverage for IVF with surrogacy is very tricky. Read each law carefully to determine if the rules explicitly include or excludes surrogacy. In addition, most plans will not pay for the surrogate’s pregnancy and delivery.
  • Self-insured employers are exempt from state mandates. They follow federal rules.
  • Religious employers often object to supporting assisted reproductive because of embryo destruction and other reasons. Most rules exempt religious employers from the requirements.

Mandatory States

Couples living in one of the fifteen states with an infertility mandate have no guarantee of coverage. In addition to the many exclusions noted above, each requirement has unique wrinkles that determine who does or does not win this crazy and confusing lottery.

  • The state where the issuing company writes the policy determines if the legal directive applies. The industry defines this as the “In Situs” jurisdiction. A group plan written (Sitused) in a non-mandate jurisdiction does not have to offer infertility benefits to employees living or working elsewhere.
  • Both California and Texas have mandates to offer. The means that the issuing carriers must offer at least one group plan with the required benefit. Employer groups can purchase a policy with a fertility rider, or one without the rider.
  • Group and individual markets have different requirements. Some directives apply only to large groups (25 or 50 plus more employees), while others include groups of 2 or more employees.
  • Plan design is also a factor. Some mandates pertain only to Health Maintenance Organizations (HMO). Residents in a Preferred Provider Organization (PPO) design do not qualify.
StateInfertilityIVFMarket
ArkansasNoYesInd & Group
CaliforniaYesNoGroup
ConnecticutYesYesInd & Group
HawaiiNoYesInd & Group
IllinoisYesYesGroup 25+
LouisianaYesNoInd & Group
MarylandNoYesInd & Group 50+
MassachusettsYesYesInd & Group
MontanaYesNoHMO
New JerseyYesYesGroups 50+
New YorkYesNoInd & Group
OhioYesNoHMO
Rhode IslandYesNoInd & Group
TexasNoYesGroup
West VirginiaYesNoHMO

Source: National Conference of State Legislators

It makes senses to continue COBRA insurance if your group plan is subject to any of these legal requirements. The COBRA benefits remain the same after a person separates from an employer. It may be difficult to find an alternate on the individual market.

Non-Mandate States

Couples living or working in a non-mandate state can still find health insurance covering infertility or IVF treatments. However, the odds are much lower and the enrollment process is very difficult. Recall the first point noted in the section above.

The jurisdiction where the issuing company writes the policy determines if the legal directive applies.

Many large employers write their group policies in mandate states. If they do not self-insure (which many large employers do) then the requirements apply to employees working across the country.

  • Take Pennsylvania residents as a good example of this reverse loophole. Pennsylvania shares a border with four mandate states. Large employers headquartered in one of those four jurisdictions are likely to have satellite offices in Pennsylvania. Those workers could enjoy the coveted coverage.
  • Take Florida residents as a poor example of the reverse loophole. Florida is a peninsula. The two bordering neighbors do not have legal requirements. Only nationwide employers from mandate states are likely to have offices in Florida.

The enrollment process is very difficult for residents of non-mandate regions. First, they must identify employers offering infertility benefits with offices near where they live. Then, they must apply for a job and convince the company to hire them.

However, if the employer group covers multiple IVF cycles, changing jobs for less pay could work in your favor.

Employer-Based Group IVF Coverage

Where do couples living in a non-mandate state find nationwide employers that offer group health insurance covering infertility or In Vitro Fertilization treatments? Below is a list of employers with locations nationwide.

Use the list as possible employment targets, but also as an example of how to research their employee benefit offerings. Some cover Assisted Reproductive Treatments (ART) because they are subject to legal requirements. Others in hyper-competitive industries purchase an infertility rider voluntarily to attract and retain personnel.

Some employers offer a hidden form of financial assistance. Do not overlook the value of an employer-sponsored Flexible Spending Account (FSA). An FSA makes treatments much more affordable.

Federal Government

The federal government is the largest nationwide employer in the United States. The U.S. Office of Personnel Management (OPM) works to “recruit, retain, and honor a world-class workforce for the American people.”

The OPM voluntarily offers benefits not required by law.

The federal government employee health insurance plan offers the required benefits for ART to employees working in legal directive states. It does this to stay on par with private industry employers.

In addition, the federal plan covers the diagnosis and selected treatments of infertility for employees working in non-mandate regions. It does this in order to compete for skilled workers.

  • Included Benefits
    • Artificial insemination
      • Intravaginal insemination (IVI)
      • Intracervical insemination (ICI)
      • Intrauterine insemination (IUI)
    • Fertility drugs
      • Injectable medications
      • Oral pills
    • Excluded Benefits
      • In Vitro Fertilization (IVF)
      • Embryo transfer and GIFT
      • Services and supplies related to excluded ART procedures
      • Cost of donor sperm

State Government

The state government is the next large public employment sector that might offer medical insurance covering IVF and other infertility treatments. Of course, state government by definition does not employ many people nationwide. Therefore, the breakdown works differently.

  • State medical insurance plans are often subject to infertility legal directives. Residents working for exempt private employers might benefit from changing to a civil service career.
  • State government employees are heavily unionized. Their collective bargaining agreements often result in gold-plated benefits – which may include coverage for assisted reproduction in non-mandate areas.

Armed Forces

Joining the military is an option to obtain medical insurance covering ART – with limits. Military service members and their families may be eligible for one of three programs. Read the list of included and excluded services for each plan very carefully before deciding to enlist.

  • Tricare– is a healthcare program providing for uniformed service members, retirees, and their families. Tricare covers infertility services that are medically necessary and combined with natural conception. Military service members injured in the line of duty sometimes qualify for additional services such as IVF and artificial insemination.
  • The Veterans Health Administration (VA) is America’s largest integrated healthcare system with over 1,700 sites of care, serving 8.76 million veterans each year. VA benefits include infertility assessment, counseling, and specific treatments for male and female veterans.
  • Champ VA – The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered services and supplies with eligible beneficiaries. It includes infertility testing and treatment, including correction of the physical cause.

Private Industry Groups

Employers in private industry sometimes offer health insurance covering infertility or IVF treatment. They provide the coverage when subject to a legal requirement. In addition, those in industries with high-demand skilled workers often purchase riders in order to compete for effective personnel.

These are the most likely and least likely industries to offer ART benefits voluntarily.

Most LikelyLeast Likely
Information Technology (IT)Retail
Accounting & FinanceFood Service
MedicalHospitality

Boeing

Boeing employs 145,000 people nationwide concentrated in ten different states. Boeing headquarters Washington State and may write their policy under these laws. Washington State does not have a legal directive and the Boeing benefits for assisted reproduction reflect this.

The plan will pay claims for the following services in connection with the diagnosis and treatment of infertility

  • Office visits, laboratory services, and prescription drugs
  • Diagnostic tests necessary to determine the cause
  • Surgical correction of a condition causing or contributing to infertility

The plan will not cover any of these procedures

  • Artificial insemination
  • Embryo transfer
  • Fertility drugs when associated with artificial means of conception.
  • Gamete intrafallopian transfer (GIFT)
  • In vitro fertilization (IVF)
  • Microinjections
  • Sperm preparation
  • Sperm separation
  • Zona drilling

Costco

Costco employees 174,000 retail workers in stores across the country. Costco also headquarters in Washington State (no mandate) and the in-network plan for full-time employees follows suit. It does not pay for any infertility procedure including IVF (except the diagnosis and treatment of the underlying medical condition).

Disney

The Disney Company employs 166,000 people in 40 different countries. It is very difficult to provide a single reliable answer to their coverage for infertility or IVF. However, the factors making it so hard to determine may help readers learn how to spot other prospective employers with the coverage they want.

  • Theme park cast members reside in either California or Florida. CA has a legal directive to offer while FL has nothing. If Disney writes separate policies in each location, the benefits could be very different.
  • Theme park and cruise ship cast members do not possess in-demand skills. Therefore, the need to offer superior benefits voluntarily is not strong.
  • Part-time cast members can enroll in limited benefit medical plans. It is very unlikely that these stripped down offerings pay claims for any infertility-related services.
  • Technology and executive workers possess high-demand skills. Disney may decide to carve out a separate program with extra coverage for these employees.

FedEx

Federal Express (FedEx) employs over 400,000 team members globally. It is also very difficult to determine their coverage for IVF or infertility treatment. The Fedex headquarters are in Tennessee, which does not have a mandate.

  • The plan for low-skill package handlers and drivers may have fewer benefits
  • Benefits for high-skill pilots and tech workers might be better.

Hobby Lobby

Hobby Lobby is a large Arts and Crafts retailer with stores across the country. The Hobby Lobby headquarters are in Oklahoma, which does not have a legal directive.

Hobby Lobby is a secular company espousing Christian values. It famously filed a Supreme Court challenge to Obamacare birth control requirements – citing religious objections. Therefore, it is unlikely that their health care offering covers IVF due to the inherent destruction of embryos.

Starbucks

Starbucks is a large nationwide coffeehouse chain, also based in Washington State, which has no mandate. Starbucks offers a lifetime benefit of $20,000 for IVF and other ART procedures. The voluntarily offer this rare employee benefit in order to attract and retain baristas.

UPS

United Parcel Service (UPS) is a package delivery service headquartered in Georgia – yet another non-mandate state. The UPS plan for retired employees echoes the established pattern.

All options cover the diagnosis of the cause of infertility and/or medical treatment to correct that cause. However, no procedures and services, including lab and X-ray, intended to induce pregnancy (rather than to treat an underlying medical cause) are covered.

  • Artificial insemination
  • In vitro fertilization with embryo transfer
  • Intrafallopian transfer
  • Sperm banking/semen specimen storage
  • Artificially assisted fertilization
  • Infertility counseling for, or related to, artificially assisted fertilizations
  • Services for and costs of a surrogate mother

Walmart

Walmart is a big box retailer based in Arkansas – an IVF mandate state – with stores throughout the country. However, the Health Savings Account offered to store personnel explicitly excludes coverage for infertility treatment of any kind.

Walmart employs a large number of low-skill and part-time personnel. They have little incentive to pay for expensive elective services.

Blue Cross Blue Shield and Other Companies

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

Blue Cross Blue Shield is a national federation of affiliated enterprises using this trade name. BCBS is actually thirty-seven different independently operating organizations rather than one. Many affiliates write policies in a single state, while others serve wide regions.

Multiple Blue Cross Blue Shield affiliate companies create another layer of confusion. They often operate under a different name. Here is a partial list of these organizations.

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

Each BCBS affiliate operates as an independent insurance company. Other private companies work in a similar fashion – just with a different brand name. They offer Medicare supplements, Medicaid programs, employer group, and individual policies.

Medicare

Medicare is a public health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease.

  • Medicare Part A pays for inpatient hospital stays, which does not apply.
  • Part B pays for certain doctors’ services, outpatient care, medical supplies. Medicare Part B may cover medically necessary fertility treatments, but never IVF.
  • Medicare Part D pays for prescription drug coverage but excludes fertility medications.

Blue Cross Blue Shield and other private insurance companies offer Medicare Advantage and/or supplemental plans. They fill the gaps in Parts A and B.

Medicaid

Medicaid is a public health insurance program that provides basic support for low-income families. You must meet income and asset means testing to qualify.

Medicaid does not pay claims for any ART procedures. Regional legal directives do not apply to publically funded programs. Medicaid offers basic support only. Medicaid does cover pregnancy and sometimes pays for dental work and eye care.

Medicaid programs also have many confusing name variations. Some states assign unique consumer-friendly monikers (BadgerCare, Family Care, etc.). In addition, private companies issue and manage Medicaid compliant programs. For example, large insurers such as Aetna, Blue Cross Blue Shield, and many others issue Medicaid plans.

Company versus Plan

The other private insurance companies will not pay for any Assisted Reproductive Technology (ART) for a policy (individual or group) absent a legal dictate or an employer requiring the benefit. These requirements pertain to plans rather than companies.

  1. ART is expensive and benefits a small portion of the population. The carrier must raise premiums to everybody to make the numbers work. Most buyers will choose a lower cost plan offered by a competitor.
  2. ART is not medically necessary. Members do not experience physical pain, risk the use of a bodily organ or limb, or face death.
  3. ART often results in pregnancy, which generates claims that are far more expensive nine months later. High-risk pregnancy and/or multiple births are more expensive still. This raises premium costs for everyone.

Each insurance company issues a wide variety of plans. Each plan has unique benefits and features including what treatments it may cover and the deductible and other cost-sharing components.

Do not confuse branded healthcare company names with the plans they issue or the role they play in the marketplace.

Traditional Healthcare Companies

Many branded insurance companies issue combinations of Medicare, Medicaid, group, and individual medical plans. In addition, each branded corporation operates in different regions. Therefore, each has a unique mixture of plans subject to ART legal directives.

The coverage for IVF and other infertility treatments for branded providers are literally all over the map.

  • Aetna operates in all fifty states. Therefore, some plans are subject to mandates and must pay claims for ART. However, most will not.
  • CIGNA offers plans in ten states. Three have obligations. Cigna covers treatments when compelled.
  • Emblem Health is the umbrella corporate name for GHI and HIP plans serving the New York State region. NYS has an ART requirement that excludes IVF.
  • Kaiser Permanente is a California-based provider serving the Golden State. California has a legal requirement for carriers to offer a plan covering ART – but it does not include IVF.
  • Geisinger Health offers Medicare, Medicaid, and individual plans in Pennsylvania. Geisinger has no legal requirement or employer group requesting coverage for ART procedures.
  • Humana markets individual and group plans in twenty-two states. None of these has a legal directive.
  • MVP offers plans for individuals and employers in New York and Vermont. Some MVP options issued in New York would cover ART – but excluding IVF – as per the law.
  • Tufts Insurance offers Medicare, Medicaid, and private industry programs. The Tufts private industry policies issued in Massachusetts and Rhode Island offer the required ART benefits
  • United HealthCare is a health services provider national in scope. United HealthCare is required to pay for ART when it writes policies in one of the fifteen mandate states.

Supplemental Insurance Companies

Supplemental insurance companies issue policies that cover the outcome of ART procedures. After mom becomes pregnant, she may need to stop working before her due date. Most women take an unpaid maternity leave. Delivery in a hospital often results in large medical bills.

Here are some of the largest carriers in this category.

  • AFLAC
  • Colonial Life
  • Humana
  • UNUM
  • Prudential

Pharmacy Benefit Managers

Health insurance companies often contract with third-party Pharmacy Benefit Management (PBM) firms. These firms specialize in lower-cost mail order delivery of prescription medications and claims approval and billing.

The PBM name often appears on the member’s card. However, they do not decide whether to pay claims for fertility medications or not. A PBM simply applies the rules as dictated by the issuing company.

  • CVS Caremark is a Pharmacy Benefit Management firm. CVS Caremark bills patients based on the insurer’s instructions.
  • Express Scripts recently merged with Medco to form the largest PBM. Express Scripts/Medco does not make coverage decisions on any IVF medications they fulfill.

Third Party Administrators

Third party administrators provide back-office support for self-insured employers. Many traditional medical insurance companies provide a similar service. Members interface with these organizations to obtain pre-approvals and process claims.

However, they implement rules specified by the self-insured employers.

  • MagnaCare offers healthcare solutions for trade unions and self-insured employers. Self-insured employers are exempt from state legal directives. Therefore, MagnaCare plans may pay for ART only when employer groups voluntarily include the benefit as a rider.
  • UMR is a third-party administrator (TPA), hired by your employer, to help ensure that your claims are paid correctly. UMR may primarily service self-insured employers that are commonly exempt from mandates. Therefore, most UMR plans may not cover ART unless the employer group requests the benefit.

Posted 08/18/17 5:20 PM by Kevin Haney MBA