Know your rights: The Montana Fertility Coverage Mandate

The Montana infertility mandate, enacted in 1987, requires HMOs to provide coverage for “infertility services” as a basic health care service that must be covered but it doesn’t define infertility or which services must be covered. Further information is clarified in Section 33-31-102 of the Montana Code Annotated which last updated in 1996. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

This law doesn’t provide a specific definition for infertility. The most widely recognized definition of infertility is “Inability to conceive after 12 months of unprotected sexual intercourse.”

Eligibility requirements

Patient requirements: There are no patient requirements defined by the law. Coverage would likely

Insurance Requirements: The law only extends to HMO plans and does not require coverage of infertility services for other types of insurance plans.

How the law treats male infertility

The law does not distinguish between male and female infertility.

Services that are covered

The law does not specify which diagnostic tests, medications, services or procedures would be covered. This would likely vary by insurance provider. Most providers have a statement about what they cover.

Exemptions

Under this mandate, non-HMO plans (like PPOs, high deductible plans, etc) are not required to provide coverage and are explicitly exempt from from providing coverage for reversal of sterilization, artificial insemination, or treatment for infertility.

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: Because the mandate only extends to HMO plans, it is a good idea to know what they are and find out if your employer offers them. If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.  You should also look up your insurance provider’s statement on fertility services. Because the law is ill defined, each provider is likely to define services differently and ave different requirements. Generally, HMO’s follow medical guidelines and will require people to try least expensive and invasive treatment options before authorizing higher cost procedures. Getting an understanding of how your insurance treats fertility problems can help you know what your options are and help you better communicate with your doctor.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:

Does insurance cover male infertility?

When you are trying to grow your family and month after month passes with no pregnancy, the wheels start turning, what could be going on? Doctors are great resources, but they can be expensive and one of the first questions to come to mind is: Will my insurance cover male fertility related expenses?

Health Insurance 101

In 2016, 91% of people in the United States had some sort of insurance. 75% of insured Americans get insurance through work or privately purchase it through market exchanges. The rest get coverage through government sponsored plans which include Medicare, Medicaid and Military health plans. The most common private insurance plans are PPO plans (48%) High Deductible plan (14%) and HMO (10%).

What’s the difference between PPO, HMO and High Deductible plans?

PPO (Preferred Provider Organization): PPOs share the cost of healthcare with you. When you visit the doctor, you pay some and the plan pays some. If you go to a doctor that is part of the PPO network, you will pay less. PPO plans usually have an annual deductible and an annual out-of-pocket maximum that ensure you won’t go completely broke if you develop a costly medical condition (like cancer). PPOs generally give you more control over your care by enabling you to go directly to specialists without having to see a primary care doctor first. However, to keep tabs on cost, they generally will also require a pre-approval for any expensive medical tests or procedures that forces the doctor to submit proof that a given test or procedure is medically necessary.

High-Deductible Plans: High-deductible plans are generally structured like PPOs but have a very high annual deductible that you must pay out of pocket before the insurance will start to share health care costs with you. These plans force consumers to pay for most of their medical expenses out-of-pocket but offer a safety net should you develop a costly medical condition. High deductible plans enable you to open a health savings account using pre-tax money. Many employers that offer high-deductible plans may also contribute to the health savings account lowering the out-of-pocket health expenses. Sometimes, the low premiums associated with these types of plans cause them to be lowest cost route to paying for healthcare (especially if your employer contributes to your HSA account).

HMO (Health Management Organization): HMOs have a different philosophy about care. They have strict rules about the progression of care. You start with your general practice provider. The GP will follow protocols regarding whatever medical condition and make the necessary referrals to specialists or for additional testing, etc. HMO plans generally require consumers to pay co-pays to prevent people from over-utilizing benefits.

Additional health & wellness benefits offered by employers

Health care costs in the United States have doubled every ten years for the past several decades. To combat rising costs and to attract top employees, many companies have begun offering additional health and wellness benefits that aim to prevent chronic illness and improve overall health of employees. These benefits include health risk assessments, screening tests, smoking cessation, weight-loss, behavioral and lifestyle coaching, telemedicine or nurse hotline, Fitbits or other activity trackers and fertility related benefits. Talk to your HR department to learn about any additional health or wellness benefits offered by your employer.

Are fertility treatments covered by insurance?

Since the 1980’s several states have required insurance companies to offer fertility benefits. These laws vary in scope of coverage, eligibility and employers that are exempt.  In 2017, Mercer, a market research company released a report showing that 25% of  large employers offered fertility benefits. While the last several years have shown increased coverage for fertility care, fertility treatments remain largely out-of-pocket.

The Affordable Care Act’s impact on fertility coverage

The Affordable Care Act enacted in 2010 was created as a step to standardize insurance coverage in the United States by mandating that certain medically necessary services called essential health benefits (emergency care, maternity care, and prescription drugs for example) be covered (in some form) by all insurance plans.
Under the ACA, fertility is not explicitly called out as an “essential” health benefit that should be universally covered, but there are several fertility-related preventative care services that are offered to both men and women who are interested in growing their family. These health benefits are mandated to be offered without cost.

Starting your family is a good time to take advantage of these free health benefits to make sure you (and your future baby) are as healthy as you can be. Here are a few preventative health services that are offered for free under the ACA:

Well-woman visits: The “annual” visit to the ob-gyn for a PAP smear is a good opportunity to discuss family building and fertility concerns with the Ob-gyn.

Folic acid supplements: Folic acid is well studied to reduce birth defects and is strongly recommended for women who are pregnant or considering getting pregnant. Under the ACA they are available for free. Less-well known is the usefulness of folic acid for sperm health. Folic acid plays a critical role in DNA replication and has been shown to support healthy sperm production. So, sharing this supplement with your partner ismight be a good idea if you’re planning to get pregnant.

Sexually Transmitted Infection (STI) Testing: STIs can cause infertility in both men and women. Free screening is available for many STDs and treatment is often low cost and very effective.

Alcohol and tobacco use counseling: Alcohol and cigarettes are hard on your body. They can cause several issues with the reproductive system and impact the health of unborn children. Preventative services include screening and counseling.

Weight loss related screening and support: If you struggle with weight, a little support can go a long way to help you on the road to permanent weight loss. Covered services include health screenings and, diet and lifestyle coaching.

Preventative services covered by ACA

States mandating fertility coverage

Since the 1980s, 15 states—Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia—have passed laws that require insurers to either cover or offer coverage for infertility diagnosis and treatment. Of the 15 states with fertility coverage mandates, only 8 of them include any discussion on male infertility care.

The laws vary greatly by state in the following ways:

  • How they define infertility
  • Types of employers or insurance plans that are exempt
  • Eligibility requirements
  • Services that are covered
  • Lifetime limits on coverage

Due to the great work of Resolve, a non-profit focused on support and advocacy for people with infertility, many states have recently updated infertility mandates. There have also been updates to health policies increasing access to infertility care for veterans and active military duty personnel.

How can I find out what fertility related expenses are covered by my insurance?

As you start your research, here’s a starting point to help you identify what questions you need to ask and who might be able to answer them.

Type of plan: First things first, what type of plan do you have? Do you split costs or pay co-pays? Is there a deductible or out-of-pocket max? Do you have to start with a primary care doctor or can you choose any doctor? How can you identify what’s covered and what isn’t? Do you have fertility benefits? Make sure you have a solid understanding of how your insurance works. If you don’t understand it, make someone explain it to you.

Do you have a health spending account (FSA or HSA)? Is so, how much is contributed? How do you access it?

How do you access free preventative services? Ask your provider how to access free preventative services such as screening tests, folic acid and well woman visits. Many insurance providers and employers have other health and wellness programs that are free and worth investigating.

Map out a plan: Based on where you live, your situation, and the type of plan you have, your route to receive care may look different. If fertility isn’t covered, you may want to start with a urologist for a general men’s health check up to test testosterone levels and look for a varicocele. If it is, a semen analysis may be your best first step.

Some of the above questions can be difficult to answer, especially if you’ve never really needed to use health benefits before. Here are a few places you might turn to help you find some answers.

Talk to HR: If you don’t know much about your health benefits, HR may be a good place to start. They can help you understand some of the basics like what type of plan you have, if you have an FSA or HSA account, and if there are any health and wellness benefits beyond insurance.

Check online: Most insurance companies have an online patient portal that outlines your coverage. If you haven’t accessed this before, you can ask HR for the URL.

Pick up the phone: Your insurance card should have a phone number for member services. You can call to learn more details about how your plan works and what is covered.

Call your doctor’s office (or stop in): The front desk as a doctor’s office is an invaluable resource to help you navigate insurance. They can look up costs, make calls on your behalf, help you schedule things and serve as an invaluable source of information about local resources.

What should I do if my insurance doesn’t cover infertility treatments?

If your insurance plan does not cover infertility treatments, all is not lost. It may take some creative thinking and planning on your end but there is still a lot you can do:

Learn what things cost: Knowing costs associated with different tests and treatments allows you to plan. You can get a general idea of cost range through internet research, but you should call your physician to get specifics as prices vary by practice. Some practices may hesitate to provide costs up front not knowing what you will need. It may help to ask for costs of specific tests or treatments or to schedule an appointment with the practice financial coordinator if they have one.

Take advantage of benefits you do have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as you can will not only improve your overall fertility but can help you qualify for additional resources such as financing programs or discounts offered through fertility clinics.

Try home testing and treatment options: Recognizing the high cost of fertility care, many startups have developed new, affordable technology and services aimed at helping couples resolve fertility issues on their own at home.

Get financing: Many, if not all, fertility clinics offer financing options either in-house or through a 3rd party provider that makes fertility treatment more affordable by allowing you to make monthly payments. Some also offer discounts or shared-risk plans.

Talk to a financial counselor: Many fertility clinics have a financial counselor on-staff who is available to work with patients to develop a plan that enables them to afford fertility care. The financial counselor may be able to help you figure out what costs you are likely to incur, determine if any of the expenses are able to be billed, negotiate a payment plan, get discounts or apply for financial assistance.

Apply for financial assistance: There are several small non-profits who provide grants for people who cannot afford fertility treatments. As you may imagine, number of applicants greatly exceeds the grants available, but they are worth a shot if you really don’t have any other options.

References and Resources

James M Dupree Insurance coverage for male infertility care in the United States Asian J Androl. 2016 May-Jun; 18(3): 339–341.

United Healthcare Infertility Diagnosis and Treatment Medical policy January 1, 2017

Farland LV1, Collier AY2, Correia KF3, Grodstein F4, Chavarro JE5, Rich-Edwards J6, Missmer SA7. Who receives a medical evaluation for infertility in the United States? Fertil Steril. 2016 May;105(5):1274-1280. doi: 10.1016/j.fertnstert.2015.12.132. Epub 2016 Jan 16.

Jessica C. Barnett and Edward R. Berchick Health Insurance Coverage in the United States: 2016 United States Census Bureau, Report Number: P60-260 September 12, 2017

G Claxton, M Rae, M Long, A Damico, G Foster, H Whitmore, Employer Health Benefits 2017 Annual Survey Kaiser Family Foundation and Health Research & Educational Trust 2017

Mercer, National Survey of Employer-Sponsored Health Plans, 2017

Know your rights: The Massachusetts Infertility Mandate

The Massachusetts infertility mandate, enacted in 1987, is hailed as one of the most comprehensive in the country by requiring infertility be treated like any other medical condition and not mandating a cap on coverage (either in number of cycles or a lifetime dollar amount). Individual insurance policies do have the right to limit the number of cycles covered based on clinical guidelines or patient medical history. In 2005, the state expanded coverage to state funded health programs.

Further information is clarified in the Massachusetts General Laws, Chapter 175, Section 47H. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

The Massachusetts mandate defines infertility as “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.”

Eligibility requirements

Patient requirements: Patient must be a policy holder or the spouse (and covered dependent) of the policy holder and be diagnosed with infertility (as defined above). Additionally, IVF can only be covered if patient is unsuccessful achieving pregnancy with less expensive treatment options covered by the plan.

Clinic Requirements: IVF procedure must be performed at a fertility clinic or medical facility that conforms to standards and guidelines set by the American Society for Reproductive Medicine (ASRM) or the American College of Obstetricians and Gynecologists. Procedures must be recognized by a scientific body such as the American Society of Reproductive Medicine, American College of Obstetrics and Gynecology or the Society of Assisted Reproductive Technology. Experimental procedures will not be covered.

How the law treats male infertility

The law does not specifically define coverage requirements for male related services and treatments. However, Chapter 46, section 4B explicitly creates paternal rights for married men whose wives conceive via artificial insemination or IVF with donor sperm.

Services that are covered

All approved fertility treatments are covered. Insurers are required to treat infertility like any other condition. The following treatments are specifically listed in the mandate:

  • Artificial insemination or IUI
  • IVF
  • GIFT
  • Sperm, egg and/or inseminated egg procurement and processing
  • Banking of sperm or inseminated eggs, to the extent such costs are not covered by the donor’s insurer,
  • ICSI
  • ZIFT
  • Assisted hatching
  • Cryopreservation of eggs.

Additional protections: The law goes out of the way to protect infertility patients by requiring co-pays and deductibles for fertility related expenses to be the same as all other conditions, prohibiting pre-existing condition clauses and placing caps on the amount of cycles that can be covered.

Limitations on coverage

The following procedures identified in the mandate as exempt:

  • Sterilization procedures or reversals (vasectomy or tubal ligation)
  • Surrogacy
  • Experimental fertility treatments
  • Egg freezing

Exemptions

The following organizations are exempt from providing coverage:

  • Self-ensured organizations
  • Companies that are not headquartered in MA

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:

Know your rights: The Maryland Infertility Mandate

The Maryland infertility mandate, enacted in 1985, requires group insurance carriers that offer pregnancy benefits to also cover diagnosis and treatment for infertility including in vitro fertilization (IVF) procedures. This law is more generous than most by allowing 3 IVF cycles per live birth and a lifetime maximum of $100,000 worth of coverage. Recently, Maryland updated the mandate to enable use of donated sperm or eggs and to cover same sex couples who have difficulty conceiving.

Further information is clarified in the Maryland Insurance Article Section 15-810 last updated in July 2016. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

To qualify for treatment, you must have one of the following conditions:

  • Unexplained infertility for at least 2 years
  • Endometriosis
  • DES (In Utero to Diethylstilbestrol)
  • Blockage or removal of fallopian tubes (not including voluntary sterilization)
  • Male Infertilty
  • 6 failed artificial inseminations for same sex couples

Eligibility requirements

Patient requirements: Patient must be a policy holder or the spouse (and covered dependent) of the policy holder, be diagnosed with infertility (as defined above)and must be unsuccessful achieving pregnancy with less expensive treatment options covered by the plan.

Clinic requirements: IVF procedure must be performed at a fertility clinic or medical facility that conforms to standards and guidelines set by the American Society for Reproductive Medicine (ASRM) or the American College of Obstetricians and Gynecologists.

How the law treats male infertility

Maryland may be one of the most friendly mandates towards male infertility. It calls out “male factors” and “oligospermia” as causes of infertility. It also covers the use of donor sperm in an IVF cycle if “the patient’s spouse is unable to produce and deliver functional sperm, and
the inability to produce and deliver functional sperm does not result from a vasectomy or another method of voluntary sterilization.” It does not however mandate infertility services that are for men such as sperm retrieval, varicocele correction or use of fertility drugs to improve sperm production.

Services that are covered

While other fertility treatments may be covered at the discretion of the insurer, In Vitro Fertilization is the only treatment specifically called out in the mandate. Donor sperm may be used for sex sex couples and hetrosexual couples for whom the male partner is unable to produce functional sperm.

Limitations on coverage

  • Does not cover reversal of sterilization procedures (vasectomy or tubes tied)
  • Does not cover IVF if either partner has undergone sterilization procedure
  • 3 IVF cycles per live birth
  • Lifetime benefit not to exceed $100,000

Exemptions

The following organizations are exempt from providing coverage:

  • Employers with fewer than 50 employees
  • Religious organizations
  • Self-ensured organizations

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:

Know your rights: The Louisiana Infertility Mandate

The Louisiana infertility mandate, enacted in 2002, makes it illegal to exclude coverage for a medical condition just because it results in infertility. It does not require coverage for fertility drugs, treatments or sterilization (getting vasectomy or tubes tied). This law is one of the weakest mandates as it doesn’t require coverage for infertility care. It simply states that insurance plans cannot exclude coverage for correctable medical conditions that result in infertility.

Further information is clarified in the Louisiana Insurance Code. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

It does not provide a definition of infertility.

 

Eligibility requirements

Patients that have a correctable medical condition cannot be denied treatment solely because treatment may result in infertility.

How the law treats male infertility

The law does not distinguish between male and female infertility, so presumably men are covered.

Services that are covered

No explicit services are called out as required to be covered.

Limitations on coverage

The law does not require coverage for fertility drugs, fertility treatments or sterilization procedures.

Exemptions

Self insured employers are exempt from the mandate.

Tips & Resources

The Louisiana mandate does little to ensure coverage of infertility care by insurance companies. This doesn’t mean that you don’t have coverage, but it does mean you are going to need to do some extra homework to understand what (if any) benefits are available to you. We’ve put together a primer article on how health insurance works and how to figure out what your benefits are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:

Know your rights: The Illinois Infertility Mandate

The Illinois infertility mandate, enacted in 1991, requires group insurers and HMOs who provide pregnancy related benefits to also provide coverage for fertility treatments, including in vitro fertilization (IVF).

Further information is clarified in the Illinois Insurance Code which last updated in 1996. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

Illinois uses a conventional definition of infertility: “the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.”

Eligibility requirements

  • Patient must be covered by eligible plan and be unable to conceive after 12 months of unprotected intercourse.
  • IVF procedure must be 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.

How the law treats male infertility

The law does not call out male infertility care specifically and male infertility services would be covered at the discretion of the insurer.

Services that are covered

Other fertility treatments may be covered at the discretion of the insurer, but the following services are explicitly listed in the mandate:

  • Diagnostic Tests
  • Artificial insemination
  • In vitro fertilization (IVF)
  • Uterine embryo lavage
  • Embryo transfer
  • Gamete intrafallopian tube transfer
  • Zygote intrafallopian tube transfer
  • Low tubal ovum

Limitations on coverage

A patient is limited to a lifetime maximum of 4 egg retrievals. If live birth occurs, patient becomes eligible for additional 2 egg retrievals for a second pregnancy.

Exemptions

The following organizations are exempt from providing coverage:

  • Employers with fewer than 25 employees
  • Religious organizations
  • Self-insured organizations

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups)

References:

Know your rights: The Hawaii Infertility Mandate

The Hawaii infertility mandate, enacted in 1989, requires any fertility coverage, including a single IVF cycle, in any plan that also provides maternity coverage for couples who have been trying unsuccessfully to conceive for 5 years or who have been diagnosed with a condition known to cause infertility.

Attempts to amend the bill in 2012 to include fertility preservation for people of reproductive age diagnosed with cancer and again in 2017 to open access to single women and same sex couples died in committee meetings.

Further information is clarified in the Hawaii Revised Statutes Section 431-10A-116.5. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

To qualify for treatment, you must have one of the following conditions:

  • Unexplained infertility for at least 5 years
  • Endometriosis
  • DES (In Utero to Diethylstilbestrol)
  • Blockage or removal of fallopian tubes (not including voluntary sterilization)
  • Male Infertility

Additional Eligibility requirements

  • Patient must be a policy holder or the spouse (and covered dependent) of the policy holder.
  • Must be diagnosed with infertility (as defined above).
  • Must be unsuccessful achieving pregnancy with less expensive treatment options covered by the plan.
  • Eggs of patient must be fertilized by Husband’s sperm.
  • The IVF procedure must be performed at a fertility clinic or medical facility that conforms to guidelines for IVF established by the American College of Obstetric and Gynecology or the American Society for Reproductive Medicine.

How the law treats male infertility

Like Arkansas, the treatment of male infertility is a mixed bag. On one hand, the law explicitly defines “abnormal male factors” as a cause of infertility but does not explicitly cover “male infertility treatments” and requires that IVF utilize husband’s sperm and wife’s eggs, precluding use of donor sperm.

Services that are covered

The mandate suggests that less expensive fertility treatment options should be covered (and utilized prior to use of IVF) but only specifies that a single cycle of In Vitro Fertilization must be offered to those who qualify.

Limitations on coverage

Only one IVF cycle is required to be covered. Cycles using donor sperm or eggs are not covered under the mandate. Same sex couples or single women are not eligible for treatment under the mandate.

Exemptions

Self-insured organizations are not required to offer coverage.

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:

Know your rights: The Connecticut Infertility Mandate

The Connecticut infertility mandate, enacted in 1989, requires health insurance organizations to provide coverage for medically necessary expenses in the diagnosis and treatment of infertility, including IVF procedures. It was amended in 2005, to allow exemptions for religious organization from coverage that is contrary to religious beliefs and again in 2016 to remove age limits on benefits and to explicitly include male infertility.

Further information is clarified in the Connecticut Bulletin HC-104 which became effective January 1, 2016. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

The legal definition of infertility in this mandate is “the condition of an otherwise healthy individual who has been unable to conceive or sustain a successful pregnancy during a one-year period.”

Additional Eligibility requirements

Insurance requirements: Patients must be policy holders for 12 months and must disclose prior fertility treatments (covered by a different plan) to the insurance provider.

Medical requirements: Patient must be healthy, and treatment must be medically necessary. Doctors or insurance providers may use reasonable medical management to determine if the patient is healthy or if the treatment is necessary. Note that as of 2016, age has been removed as a reason to exclude treatment.

Medical facilities: Fertility treatments must be performed at fertility clinics or facilities that conform to the guidelines developed by the American Society for Reproductive Medicine (ASRM) or the Society of Reproductive Endocrinology and Infertility.

How the law treats male infertility

The Connecticut mandate is one of the few states that explicitly covers male infertility through a 2016 amendment that states “Male infertility treatment is covered under this mandate.”

Services that are covered

Other services may be covered at the discretion of the insurance company, but the following services are explicitly called out by the mandate.

  • Ovulation induction
  • Intrauterine Insemination (IUI)
  • In Vitro Fertilization (IVF)
  • Uterine embryo lavage
  • Embryo Transfer
  • Gamete Intrafallopian Transfer (GIFT)
  • Zygote Intrafallopian Transfer (ZIFT)
  • Low tubal ovum transfer.

Limitations on coverage

  • Lifetime maximum 4 cycles of ovulation induction
  • Lifetime maximum of 3 IUIs
  • Lifetime maximum of 2 cycles of IVF, GIFT, ZIFT, low tubal ovum transfer with no more than 2 embryos per cycle

Exemptions

The following organizations are exempt from providing coverage:

  • Religious organizations
  • Self-insured organizations

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as you can will not only improve your overall fertility but since the mandate requires patients to be healthy prior to treatment chronic health conditions, high BMI, tobacco use and other health issues may prevent your ability to access fertility care.

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups).

References:

Know your rights: The California Infertility Mandate

The California Infertility Mandate, enacted in 1989, requires health plan to offer at least one plan that includes infertility treatment…except IVF.

Overall, the California mandate is pretty weak. It only requires insurance companies to offer at least one plan that has coverage for infertility care, but it doesn’t require employers to offer these plans nor does it require any plans to include coverage for IVF. The law was amended in 2013 to include clauses that made it illegal to withhold fertility services to any person who is covered, regardless of gender, gender identity, genetic information, sexual orientation or marital status (among other things).

Further information is clarified in section 1374.55 of the California Health and Safety Code which became effective in 1990. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

To qualify for treatment, you must have one of the following conditions:

  • Presence of a medical condition that causes infertility, as diagnosed by a medical professional
  • Inability to conceive or carry a child to term after a year or more of unprotected sexual intercourse

Eligibility requirements

The law has no additional eligibility requirements beyond a diagnosis of infertility (as defined above) and purchasing a plan that provides infertility coverage.

The law prevents employer or health insurance companies from discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation.

How the law treats male infertility

No specific mention of male infertility.

Services that are covered

  • Diagnostic testing
  • Medications
  • Surgeries
  • Gamete intrafallopian transfer (GIFT)

Limitations on coverage

  • IVF, defined as a procedure involving an in vitro fertilization process, is excluded from the mandate
  • Coverage is not required, only the ability to purchase coverage.

Exemptions

  • No employer is required to offer insurance to employees, the law only requires that insurance companies must have at least one plan that includes fertility coverage.
  • Religious employers are specifically called out as not being required to offer coverage for any forms of treatment that are inconsistent with religious or ethical principles.
  • Employers who are self-insured are also exempt.

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what is covered and what isn’t. If your plan does not cover fertility services, you may want to look at the other options more closely during open enrollment to see if your organization offers any plans that include coverage.

Learn what things cost: Knowing costs associated with different tests and fertility treatments allows you to plan. You can get a general idea of cost range through internet research, but you should call your physician to get specifics as prices vary by practice. Some practices may hesitate to provide costs up front not knowing what you will need. It may help to ask for costs of specific tests or treatments or to schedule an appointment with the practice financial coordinator if they have one.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as you can will not only improve your overall fertility but can help you qualify for additional resources.

Talk to a financial counselor: Many fertility clinics have a financial counselor on-staff who is available to work with patients to develop a plan that enables them to afford fertility care. The financial counselor may be able to help you figure out what costs you are likely to incur, determine if any of the expenses are able to be billed, negotiate a payment plan, get discounts or apply for financial assistance.

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with others in your area in our local forums.

References:

What to expect: Cost and coverage related to male infertility care

How much do male fertility treatments cost? Infertility care is often expensive and not covered by insurance. This article provides a quick description of the diagnostics tests and treatment options related to male fertility and an idea of what out-of-pocket costs are.

Getting Tested: figuring out why you are not able to get pregnant

Step one in treating infertility is discovering the underlying cause. Statistics vary depending on the source, but infertility can be caused by issues with the female partner, the male partner or issues with both partners. Sometimes a cause cannot be identified, and the case is diagnosed as idiopathic, or “unexplained infertility.”

As a starting point, the fertility evaluation is generally considered “medically necessary” if the couple has been trying unsuccessfully for at least 12 months when the female partner is under 35 and 6 month when older than 35. If you have had cancer, served in active combat or have other conditions that are known to impact fertility (such as undescended testicles, testicular torsion, varicocele, etc), the medical evaluation may be covered sooner, (if not before) you begin trying. If you have concerns, you can always schedule an appointment with your primary doctor to discuss them and get a roadmap to your options.

To diagnose infertility, both partners should be evaluated. A woman should be able to complete an initial evaluation with her Ob-Gyn or family practice doctor. The female evaluation includes a medical / reproductive history, investigation into how well she ovulates (which may include blood tests or ultrasounds), and various tests to examine her uterus, cervix and fallopian tubes. The male evaluation typically begins with a semen analysis. If the semen analysis reveals any abnormalities a full evaluation which includes a medical / reproductive history, a physical exam and a few blood tests by a urologist who specializes in male reproductive health is recommended.

Estimates for what male fertility testing will cost out-of-pocket

About 25% of health insurance plans offer some sort of fertility coverage, which usually include the initial diagnosis. If your plan does not cover a semen analysis, there are many lot of options for an initial test.

Home tests: Home tests cost between $25 – $60 per test. Some are sold in bundles which enable repeat testing. Home test kits are convenient and a good first step to get some feedback on your fertility early in the process.

Lab tests: The general market rate for a lab semen analysis in the United States is between $100 – $300 depending on where you live. A few fertility clinics offer a free (or low cost) semen analysis to attract get new patients in the door.

If the lab or home test come back as abnormal, it is a good idea to get a full evaluation by a urologist with specialty training in male reproduction. This workup generally includes a medical history, a physical exam and blood tests to check hormone levels. If you do not have fertility coverage, you may be able to get coverage for this workup by billing it as a men’s health check. Most insurance plans cover testosterone testing and physical exams.

The cost of treating male infertility

Treatment of male infertility varies according to underlying cause and outcomes of the female workup. Many doctors like to say that that fertility is a team sport and you can’t put a game plan together without understanding what’s going on with both partners. Here are some common treatments that are often recommended to help resolve male infertility:

Lifestyle changes (Free): Several lifestyle factors such as smoking, drinking, poor diet, lack of exercise, exposure to heat, high stress and many others can contribute to male infertility. Doctors will often counsel men on small improvements that can make a big difference for their sperm. To see if you have any major risk factors, take this quick health assessment.

Testicular cooling (Free – $70): Testicular cooling has been studied as a potential way to improve semen quality, particularly in men who are  regularly exposed to high heats. Testicles need to stay at least a few degrees cooler than the rest of your body for proper sperm production, so actively cooling your testicles for 20-30 minutes a day is an easy, low-cost option that could make a big impact.

Supplements ($20 – $100 / mo): Studies have shown that certain nutrients can improve semen quality, so many urologists will recommend supplements in addition to other treatment. Supplements vary quite a bit in price and quality so do your research. More expensive doesn’t always equal better.

Medications ($100 – $3,000): Medications often prescribed for male infertility include antibiotics to fight urological infections and Clomid or hormone injections to help boost sperm count and testosterone levels. (Note: if a doctor prescribes testosterone injections, please get a second opinion. This can often cause much more harm than good when it comes to sperm.)

Artificial insemination ($50 – $1,000): Inserting sperm closer to the egg can help pregnancy happen when sperm counts are lower. There are lots of options ranging from inexpensive home kits to a medicated and monitored Intrauterine Insemination (IUI) cycle that is performed at a fertility clinic.

Male fertility surgeries ($3,000 – $15,000): Surgeries can be done to treat varicoceles, reverse vasectomy, correct other plumbing issues or retrieve sperm from inside the testicle. Cost varies by type and complication of the procedure. Coverage varies by condition and state.

In Vitro Fertilization (IVF) ($10,000 – $20,000/ cycle): In-vitro fertilization is a commonly recommend treatment for severe male infertility. Cost can vary by type of cycle (medicated fresh or frozen or unmedicated), fertilization technique, additional testing and type of medications used. Coverage varies by state.

Planning ahead: how to afford fertility treatments

The high costs of fertility care can feel like kicking a man when he’s down. But here are a few tips that can help you put together a plan that helps you build your family without going broke:

1. Find out what your insurance will cover: You won’t know if you don’t ask. If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what is covered and what isn’t.

2. Start with low cost options and move up: Many male fertility issues can be resolved inexpensively. Getting tested early in the process gives you more time to try things like supplements or lifestyle changes before jumping to more expensive and invasive treatment options.

3. Get educated: Healthcare is a little like taking your car to the mechanic, getting educated on options and costs will help you make more informed decisions. Getting a second opinion, doing research online and connecting with organizations like Fertility within Reach or Resolve can help you feel more confident in your next steps.

4. Talk to a financial counselor: Most fertility clinics have a financial counselor on staff to help you navigate costs, figure out benefits, negotiate discounts, develop a payment plan or apply for financial assistance

Resources & References

Practice Committee of the American Society for Reproductive Medicine Diagnostic evaluation of the infertile female: a committee opinion American Society for Reproductive Medicine, Birmingham, Alabama 2015

Practice Committee of the American Society for Reproductive Medicine Diagnostic evaluation of the infertile male: a committee opinion American Society for Reproductive Medicine, Birmingham, Alabama 2015

Fertility within Reach, a national non-profit that increases access to fertility treatment and benefits by educating patients, policymakers and service providers with proprietary and evidence-based data through personalized consultations, workshops and legislative testimonies.

Resolve, a 501(c)3, national patient advocacy organization that provides free support groups in more than 200 communities; is the leading patient advocacy voice; and serves as the go-to organization for anyone challenged in their family building.