Infertility treatments fall into health insurance ‘gray area’
Many people mistakenly believe that the health reform law sets in stone what the nation’s health care system will become in future years. However, there still are dozens of provisions and regulations that remain in limbo. One of the biggest questions is what, exactly, insurers will be required to cover to achieve the reform law’s minimum standards of care.
Infertility treatment coverage is one such gray area that is being considered by federal officials and being pushed by consumer advocates and insurance companies alike.
Health care reform and infertility coverage
Once the health insurance mandate goes into effect, all insurance companies’ plans must include certain “essential benefits,” according to Kaiser Health News. When it comes to infertility coverage, the key question is whether the treatment is considered “medically necessary.” Until that is decided, infertility treatment will be just one of many other treatments (such as those for autism therapy, maternity and obesity) that sit between what is medically necessary and what is elective.
Some may argue that any comprehensive health package must include infertility treatments. In vitro fertilization costs thousands of dollars, which many Americans can’t afford out of pocket. Yet including such expensive procedures in a package that everyone is required to buy could make premiums unaffordable, according to Kaiser Health News.
What infertility coverage is offered?
As of 2011, infertility coverage involves a hodge-podge of insurance company, state and market variations.
Health insurance companies frequently use their own definitions and standards for determining infertility and the resulting level of coverage. There’s a range infertility treatments available, including in vitro fertilization, drugs that stimulate ovulation and artificial insemination. According to Kaiser Health News, insurers usually impose limits on treatment — such as a maximum number of in vitro fertilization attempts.
CIGNA, for example, first requires a couple to establish infertility based on one of the following definitions:
- The inability of opposite-sex partners to achieve conception after at least one year of unprotected intercourse.
- The inability of a woman to achieve conception after six trials of medically supervised artificial insemination over a one-year period.
- The inability of opposite-sex partners to achieve conception after six months of unprotected intercourse for a woman over age 35.
Once infertility is established, CIGNA will cover certain treatments if the patient has a plan that covers them.
In addition to variances among insurance companies, there are differences among state insurance laws as well. According to the Kaiser Family Foundation, 15 states mandate some form of infertility treatment coverage. Not all state regulations have the same mandates, however. And then, there are other factors that can influence coverage:
- Mandates for various insurance markets: States can mandate infertility coverage for the large-group, small-group and individual health insurance markets, according to the Kaiser Family Foundation. Because the individual market is the most expensive, some states are reluctant to mandate infertility coverage, to keep these plans from becoming unaffordable. Illinois, for example, requires infertility coverage for most health plans with at least 25 employees but not for individual health plans.
- Coverage vs. availability: States can mandate that insurers cover infertility treatments, or they can mandate that insurers offer this coverage for consumers who are willing to pay higher premiums. Typically, the state insurance commissioner helps determine how much higher the premiums can be.
Specific infertility treatments: This is really a mix of mandates. Some health insurance plans cover in vitro fertilization, but not other infertility treatments, according to Kaiser Health News. Others include some infertility treatments, but not in vitro fertilization. Still others cover physical and medical conditions that cause infertility, but not infertility treatments themselves.