Health Insurance and IVF Coverage

Infertility in the United States is and will remain a challenge for around 15% of the population. Science has made significant advances in treatment, but many couples will still need medical assistance to become pregnant. While an OB-BYN can help identify some of the potential issues, and some actually do conduct artificial insemination procedures, reproductive endocrinology is the sub-specialty of medicine that are the real experts in this field. Reproductive endocrinologists are the pros at administering IVF which stands for In vitro fertilization and is the most frequently used treatment for infertility. IVF also happens to be quite expensive which brings us to the topic at hand…. how do people pay for infertility treatment?

Normally in the United States, when an individual needs healthcare, that healthcare is paid, for the most part, by their health insurance. Health insurance in and of itself is an incredibly complex topic which we will not go deep into detail here, however, most people understand that health insurance coverage varies depending on what you need it for.

Health insurance is not required by law to cover everything. For example, many voluntary procedures are not covered at all. These include things like treatment for hair loss, male erectile dysfunction, and cosmetic procedures to name a few. Unfortunately, in most states, health insurers are also not required to cover treatment for fertility. As a result, while some initial diagnostic and screening procedures are covered, the majority of fertility treatment, including IVF, will not be covered at all in which case the patient is responsible for 100% of the cost. These costs can be $20,000, $30,000, $40,000 or more which make it incredibly challenging from a financial perspective, let alone medical one. It is estimated that around 70% of patients in the United States will not have their fertility treatment covered and will have to find a way to pay on their own. Side note, IVF Options provides tools to help patient compare the cost of clinics and procedures that otherwise are exceedingly difficult to determine. To take advantage of these tools, simply register for our portal to take advantage of these tools.

On the other side of the coin, there are a group of states that have enacted legislation that requires health insurers to provide some form of coverage for fertility. When a state has laws that requires some form of coverage, these states are typically referred to as “mandated” states which refers to the legislative mandate that requires it by law. Laws can change and while we do our best to update this information, details regarding information provided here may have changed. Also, it is especially important to note that the strength of the mandate varies substantially. This means that in one state, close to 100% of treatment might be covered but in another it might only be 10%. That said, there are currently 16 states that have some form of mandated coverage. The states are; Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia.

The states with the strongest mandates (best coverage) are generally thought to be Massachusetts, Illinois, Connecticut, Rhode Island, and New Jersey. The other states have significantly weaker mandates which will result in the patient still facing large out of pocket costs. The large number of patients facing these daunting costs is why IVF Options has created transparency and access to IVF costs so that you can compare clinics and make the best-informed decisions you can. See table here for further detail regarding the exact laws by state.

State Mandates

State Summary of Statutes
Arkansas Ark. Stat. Ann. § 23-79-510 specifies that the Arkansas Comprehensive Health Insurance Pool shall not include coverage for any expense or charge for in vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy.

Ark. Stat. Ann. § 23-85-137 and § 23-86-118 (1987, 2011) require accident and health insurance companies to cover in vitro fertilization. Services and procedures must be performed at a facility licensed or certified by the Department of Health and conform to the guidelines and minimum standards of the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine. (2011 SB 213)

California Cal. Health & Safety Code § 1374.55 and Cal. Insurance Code § 10119.6 require specified group health care service plan contracts and health insurance policies to offer coverage for the treatment of infertility, except in vitro fertilization. The law requires every plan to communicate the availability of coverage to group contractholders. The law defines infertility, treatment for infertility and in vitro fertilization. The law clarifies that religious employers are not required to offer coverage for forms of treatment that are inconsistent with the organization’s religious and ethical principles. The law was amended by 2013 Cal. Stats., Chap. 644 (AB 460) to specify that treatment of infertility shall be offered and, if purchased, provided without 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.
Connecticut Conn. Gen. Stat. § 38a-509 and § 38a-536 (1989, 2005) require that health insurance organizations provide coverage for medically necessary expenses in the diagnosis and treatment of infertility, including in vitro fertilization procedures. Infertility, in this case, refers to an otherwise healthy individual who is unable to conceive or produce conception or to sustain a successful pregnancy during a one-year period. Amended in 2005 to provide an exemption for coverage that is contrary to the religious beliefs of an employer or individual.
Delaware 18 Del. C. §3556 (2018) requires all group and blanket health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in the state of Delaware by any health insurer, health service corporation, or health maintenance organization and that provide for medical or hospital expenses shall include coverage for fertility care services, including in vitro fertilization services for individuals who suffer from a disease or condition that results in the inability to procreate or to carry a pregnancy to live birth and standard fertility preservation services for individuals who must undergo medically necessary treatment that may cause iatrogenic infertility.
Hawaii Hawaii Rev. Stat. § 431:10A-116.5 and § 432.1-604 (1989, 2003) require all accident and health insurance policies that provide pregnancy-related benefits to also include a one-time only benefit for outpatient expenses arising from in vitro fertilization procedures. In order to qualify for in vitro fertilization procedures, the couple must have a history of infertility for at least five years or prove that the infertility is a result of a specified medical condition.
Illinois Ill. Rev. Stat. ch. 215, § 5/356m (1991, 1996) requires certain insurance policies that provide pregnancy-related benefits to provide coverage for the diagnosis and treatment of infertility. Coverage includes in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete sperm artificial intrafallopian tube transfer, zygote intrafallopian tube transfer and low tubal ovum transfer. Coverage is limited to four completed oocyte retrievals, except if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals are covered. (1996 Ill. Laws, P.A. 89-669)
Louisiana La. Rev. Stat. Ann. § 22:1036 prohibits the exclusion of coverage for the diagnosis and treatment of a medical condition otherwise covered by the policy, contract, or plan, solely because the condition results in infertility.  The law does not require insurers to cover fertility drugs, in vitro fertilization or other assisted reproductive techniques, reversal of a tubal litigation, a vasectomy, or any other method of sterilization. (2001 La. Acts, P.A. 1045)
Maryland Md. Insurance Code Ann. § 15-810 (2000) amends the original 1985 law and prohibits certain health insurers that provide pregnancy-related benefits from excluding benefits for all outpatient expenses arising from in vitro fertilization procedures performed. The law clarifies the conditions under which services must be provided, including a history of infertility of at least a 2-year period and infertility associated with one of several listed medical conditions. An insurer may limit coverage to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000. The law clarifies that an insurer or employer may exclude the coverage if it conflicts with the religious beliefs and practices of a religious organization, on request of the religious organization.  Regulations that became effective in 1994 exempt businesses with 50 or fewer employees from having to provide the IVF coverage. (2000 Md. Laws, Chap. 283; H.B. 350)

Md. Health General Code Ann. § 19-701 (2000) includes family planning or infertility services in the definition of health care services.

Massachusetts Mass. Gen. Laws Ann. ch. 175, § 47Hch. 176A, § 8Kch. 176B, § 4Jch. 176G, § 4 and 211 Code of Massachusetts Regulations 37.00 (1987, 2010) require general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits to also provide coverage for the diagnosis and treatment of infertility, including in vitro fertilization. This law was amended in 2010 to change the definition of  “infertility” to be a condition of an individual who is unable to conceive or produce conception during a period of one year if the female is under the age of 35, or during a period of six months if the female is over the age of 35. If a person conceives but cannot 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 one year or six month period. (SB 2585)
Minnesota Minn. Stat. Ann. § 256B.0625 specifies that medical assistance shall not provide coverage for fertility drugs when specifically used to enhance fertility.
Montana Mont. Code Ann. § 33-22-1521 (1987) revises certain requirements of Montana’s Comprehensive Health Association, the state’s high-risk pool, and clarifies that covered expenses do not include charges for artificial insemination or treatment for infertility. (SB 310)

Mont. Code Ann. § 33-31-102 et seq. (1987) requires health maintenance organizations to provide basic health services on a prepaid basis, which include infertility services. Other insurers are exempt from having to provide the coverage.

New Jersey N.J. Stat. Ann. § 17:48-6x§ 17:48A-7w§ 17:48E-35.22 and § 17B:27-46.1x (2001) require health insurers to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility, including medications, surgery, in vitro fertilization, embryo transfer, artificial insemination, gamete intrafallopian transfer, zygote intrafallopian transfer, intracytoplasmic sperm injection and four completed egg retrievals per lifetime of the covered person. The law includes some restrictions as well as a religious exemption for employers that provide health coverage to fewer than 50 employees. (SB 1076)
New York N.Y. Insurance Law § 3216 (13)§ 3221 (6) and § 4303(1990, 2002, 2011) prohibit individual and group health insurance policies from excluding coverage for hospital care, surgical care and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility. The laws were amended in 2002 to require certain insurers to cover infertility treatment for women between the ages of 21 and 44 years. The laws exclude coverage for in vitro fertilization, gamete intrafallopian tube transfers and zygote intrafallopian tube transfers. The laws were amended again in 2011 by N.Y. laws, Chap. 598 to require every policy that provides coverage for prescription fertility drugs and requires or permits prescription drugs to be purchased through a network participating mail order or other non-retail pharmacy to provide the same coverage for prescription fertility drugs that are purchased from a network participating non-mail order retail pharmacy provided that the network participating non-mail order retail pharmacy agrees in advance to the same reimbursement amount and the same terms and conditions that the insurer has established for a network participating mail order or other non-retail pharmacy.  The policy is prohibited from imposing additional fees, co-payments, co-insurance, deductibles or other conditions on any insured person who elects to purchase prescription fertility drugs through a non-mail order retail pharmacy. (2011 AB 8900)

N.Y. Public Health Law § 2807-v (2002) creates a grant program to improve access to infertility services, treatments and procedures from the tobacco control and insurance initiatives pool.

Ohio Ohio Rev. Code Ann. § 1751.01 (A)(1)(h) (1991) requires health maintenance organizations (HMOs) to provide basic health care services, which are defined to include infertility services, when medically necessary.
Rhode Island R.I. Gen. Laws § 27-18-30§ 27-19-23§ 27-20-20 and § 27-41-33 (1989, 2007)require any contract, plan or policy of health insurance (individual and group), nonprofit hospital service, nonprofit medical service and health maintenance organization to provide coverage for medically necessary expenses for the diagnosis and treatment of infertility. The law clarifies that the co-payments for infertility services not exceed 20 percent. Infertility is defined as the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year.  Rhode Island includes IVF coverage.  Amended in 2007 to increase the age of coverage for infertility from forty (40) to forty-two (42) and redefines infertility to mean a woman who is unable to sustain pregnancy during a period of one year. (2007 R.I. Pub. Laws, Chap. 411, SB 453)
Texas Tex. Insurance Code Ann. § 1366.001 et seq. (1987, 2003) requires that all health insurers offer and make available coverage for services and benefits for expenses incurred or prepaid for outpatient expenses that may arise from in vitro fertilization procedures. In order to qualify for in vitro fertilization services, the couple must have a history of infertility for at least five years or have specified medical conditions resulting in infertility.  The law includes exemptions for religious employers.
Utah 2014 Utah Laws, Chap. 353 (HB 347) amended § 31A-22-610.1, which requires insurers that provide coverage for maternity benefits to also provide an adoption indemnity benefit of $4,000 for a child placed for adoption with the insured within 90 days of the child’s birth. The law was amended to allow an enrollee to obtain infertility treatments rather than seek reimbursement for an adoption. If the policy offers optional maternity benefits, then it must also offer coverage for these indemnity benefits under certain circumstances.
West Virginia W. Va. Code § 33-25A-2 (1995) amends the 1997 law and requires health insurers to cover basic health care services, which include infertility services.  Applies to health maintenance organizations (HMOs) only.

Click Here to Find The Right Fertility Clinic Near You

Start Search