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.
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