Is Infertility Treatment Covered by Health Insurance?

Given that over two million American women undergo infertility treatment in some form each year, one would think that health insurance coverage for the condition would be standard practice. In reality, though, only about 25% of employer-subsidized health plans offer coverage for infertility treatments. Financing infertility can be prohibitively expensive, which may rule it out as an option for women whose insurance plans do not provide coverage. In this post, we'll discuss the issue of infertility and insurers' reluctance to cover the condition in more depth.

Infertility Facts

Infertility is defined as the inability to conceive within a year despite having unprotected intercourse. Though the media have brought infertility issues to the fore in recent years, the number of infertile married couples has actually declined since the 1980s. The heightened awareness of the issue more than likely stems from the fact that women are delaying reproduction for career, education, etc., and thus are more likely to encounter infertility issues due to advancing age. Here are some interesting facts about infertility:

• About 15% of couples attempting pregnancy encounter infertility issues
• Issues with sperm account for 40% of infertility issues
• Age-related infertility issues are far more common with women. For men, fertility begins to decline at age 50, whereas fertility begins to decline at age 30 for women.
• 13% of women age 24-34 have infertility problems.
• 33% of women experience infertility problems by age 40
• 87% of women are infertile by age 45

Health Insurance & Infertility

Only one-quarter of employer-sponsored health insurance plans offer infertility benefits. Even when coverage is offered, the benefits can vary widely. Some plans do not cover IVF (in-vitro fertilization), other plans may demand a 50% co-pay, and some insurers will only cover certain drugs. Fifteen states have enacted infertility insurance coverage laws, but these laws are futile for many employees, as 65% of all employees participate in plans that are exempt from state mandates under federal law. Thus, for the majority of those seeking infertility treatment, out-of-pocket payment is the only option.

Pricey Treatments

The frontline of treatment for infertility is infertility medication, but even this low-tech option can get pricey. For instance, a single dose of the drug Fertinex costs about $60. On top of that, most physicians monitor the treatment process with blood tests and ultrasounds, which can raise the price to about $1,500 per cycle. If more potent drugs are used, such as Pergonal, the cost can easily double. When drug therapy fails, a patient might opt for IVF, which costs $10,000-$12,000 on average. Because the success rate of IVF increases with the number of cycles attempted (up to four), most women undergo the costly treatment more than once. If the woman fails to conceive after IVF, more complicated and even more costly treatments must be attempted. The overall cost of such treatments is staggering.

Why No Coverage?

Infertility is a medical condition, just like heart disease or diabetes, which begs the question: why don't insurers cover infertility treatments? The argument most insurers provide is that, although infertility is a medical condition, it is not a life-threatening disease like cancer, heart disease, etc. and thus does not warrant coverage. However, the logic of this argument is not exactly sound when insurers cover treatments for things like erectile dysfunction, which is hardly a life-threatening condition. Similarly, many insurers also cover birth control medications and devices, while pregnancy is also not typically regarded as a life-threatening disease, although a caesarean section is a serious operation. Insurers also present a cost-containment argument, claiming that the cost of covering infertility would lead to sky-high premiums. However, the estimated cost of adding benefits for IVF treatments to a standard health insurance package is less than $3 per member annually.

Infertility Insurance

For those whose health insurance plans do not include infertility coverage, one option is to purchase infertility insurance. Infertility insurance is coverage offered by insurance carriers to help women or couples finance their infertility treatments. The insured pays a monthly premium and, in exchange, receives at least partial coverage for infertility procedures like artificial insemination, fertility testing, and embryo transfer. If your partner needs to undergo infertility treatments, most infertility insurance policies will cover at least part of the cost of those procedures as well. Some states require that insurance companies offer infertility insurance to their customers.

Alternatives

Not many fertility clinics offer payment plans because collection rates are extraordinarily low, especially for couples who didn't end up with a live birth. To help patients with the sky-high cost of treatment, however, some clinics are expanding their payment options. For example, The Advanced Fertility Center offers a special guarantee program for its patients. In this program, the patients pay a flat rate of $16,000, for which they receive one complete IVF cycle and as many thawed-embryo transfers as are needed to achieve a birth. Patients receive a 100% refund if they do not conceive from the initial or frozen-thawed cycles.