Is IVF covered with ObamaCare?
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- Federal law does not require insurance plans to cover in vitro fertilization (IVF).
- 12 states do require certain insurance plans to cover IVF treatment.
- In general, insurance policies that cover IVF are group policies that are fully insured, as opposed to being self-insured.
Anyone having difficulty getting pregnant may want to consider getting IVF. IVF is generally not covered under ObamaCare since it’s not considered one of the essential benefits. However, several states have mandated IVF coverage. The details of insurance plans can vary significantly, so you should set aside time to learn about your different options. The specifications of your insurance policy could significantly affect your family’s future. If you need to find an insurance plan that meets your specific needs, try using a comparison tool. Enter your zip code in our FREE tool above to get an instant health insurance plan quote!
The Essential Benefits Versus the Non-Essential Benefits
Essential benefits must be covered by all insurance plans. They are:
- Emergency services
- Laboratory services
- Maternity care
- Mental health and substance abuse treatment
- Outpatient care
- Pediatric care
- Prescription drugs
- Preventive care
- Rehabilitative services
- Vision and dental care for children
In contrast, non-essential benefits are viewed by insurance companies as elective. This means that they are usually not covered. They can include:
- Weight loss programs
- Dental care
- Eye care
- Long-term care
- Infertility treatment
Though you may feel like your infertility treatment is necessary, your insurance company only has to cover the essential benefits, according to federal law.
States with Laws that Mandate Coverage of Infertility Treatments
States can set up laws that are different than the federal laws. 15 states have adopted policies which require coverage of infertility treatment. They are: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia.
However, California, Louisiana, and New York specifically exclude IVF coverage from their policies. As a result, women in only 12 states may be eligible to have IVF covered through their insurance company. Those states are:
- New Jersey
- Rhode Island
- West Virginia
Types of Policies that Cover IVF
If you’re covered through a group insurance policy (like from your employer) and live in one of those 12 states, you need to determine whether your group policy is self-insured or fully insured.
In most cases, fully insured plans will provide you with IVF coverage.
According to the Federal Employee Retirement Income Security Act (ERISA), businesses that are self-insured don’t have to comply with state laws requiring coverage. These businesses pay for medical claims with their own funds, and paying for IVF is something that they are free to refuse to do.
Employers who have fewer than 25 or 50 employees may not be required to cover IVF. In Illinois, the threshold is 25 employees, and in Maryland and New Jersey, the threshold is 50 employees.
Additionally, some states allow religious employers to be exempt from the law that requires coverage of infertility treatment. Those states are: Connecticut, Illinois, Maryland, New Jersey, and Texas.
The laws regarding IVF coverage are quite complex. It may be a good idea to consult with someone regarding coverage specific to your situation. This way, you can find the best option for your family.
What Steps Should You Take?
If you’ve been unable to become pregnant
- for one year, if you’re 35 or younger
- for six months, if you’re over 35
you should talk with your doctor. He or she may order tests to gain a better understanding of your situation. Fertility treatments usually involve fertility drugs and minor surgical procedures.
If those treatments do not work, you can discuss in vitro fertilization with your doctor.
If your insurance policy covers IVF treatments, you will usually have to submit documentation showing that you attempted to get pregnant with other methods.
Costs of IVF
In the US, IVF generally costs around $10,000 to $15,000.
IVF Success Rates
The percentage of IVF cycles resulting in live births is reported to the government. in 2010, the pregnancy success rates broken down by age were:
- Under 35: 41.5%
- 35 – 37: 31.9%
- 38 – 40: 22.1%
- 41 – 42: 13.7%
- 43 – 44: 6.6%
At a federal level, IVF is not required to be provided nor offered to patients. 12 states have adopted laws that do require the coverage of IVF, in most cases. If you’d like to pursue IVF, you should compare the insurance policies available to you to see if one may provide more coverage than the other. Start comparing health insurance plans now by using our FREE tool below!