Infertility Coverage

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Updated: Mar 28, 2023
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The problem to be addressed is the lack of mandate for insurance companies to provide coverage for infertility treatments on a national scale. Approximately ten percent of women in the United States who are of childbearing age have received professional help for infertility. However, only eleven out of the fifty states mandate coverage in the Individual Market and only fourteen states mandate to cover or offer in the Small Group Market (State Health Facts, 2019). This is an important issue because of the inconsistency in coverage.

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Additionally, since the enactment of the Affordable Care Act in 2010 which allowed states to define their own Essential Benefits Coverage, the problem worsened.

Some states that may have covered infertility treatments, had the option to no longer cover them. In 15 states, insurance companies are required to cover at least some degree of coverage for infertility treatments. According to Resolve, the National Infertility Association, treatments are covered only if the woman’s eggs are fertilized by her spouse’s sperm. Those individuals and families in the other 35 states are left to pay for the treatments in full which can cost them $40,000 to 120,000 dollars in medical and legal bills (Surrogacy, 2019). As well, they are not reimbursed and are spending up to “dollar amount”. With all of this inconsistency, there is a lot of uncertainty for individuals who are looking to receive fertility treatments but may not be able to afford them.

Policy Alternatives

One alternative to infertility treatments when attempting to gaining a child is adoption. Adoption is the legal transfer of a child to a parent or parents other than those to whom they were born. Under the Adoption Incentive program, states are able to use payments to support a range of child welfare services to children and families. Programs such as post-adoption support services, recruitment of adoptive homes, and training to improve adoption casework. With this program, it incentivizes states to promote adoptions and there are benefits for both the state and the family.

With such a program and incentives, more adoptions can take place and more families can achieve their goal of having a child (Stoltzfus, 2014). The rate of adoption has stayed relatively stable over the years. According to the Children’s Bureau, 59,400 children were adopted in 2017 and this was only a few thousands more than in 2008 of 55,300 (“Trends in Foster Care”, 2018). Adoption not only brings a child into the parent’s lives, but they gain a family as well and this option is usually a win-win for both parties involved. Adoption does vary from state to state; therefore, I propose a policy that is consistent all over the country. Each state should follow the same set of steps when going through the adoption process and afterward.

Another alternative is for every state in the U.S. to follow what the state of Connecticut does regarding coverage of infertility treatments. In 1989, the state enacted mandatory coverage for infertility diagnosis and treatments, along with limitations. The law deems that each individual health insurance policy will provide coverage for medically necessary expenses of the diagnosis and treatment of infertility.

These treatments include in- vitro treatments such as, but are not limited to, ovulation induction, intrauterine insemination, uterine embryo lavage, gamete intra-fallopian transfer, embryo transfer, and low tubal ovum transfer. Infertility refers to an individual who is otherwise healthy; however, is not able to conceive, produce conception, or maintain a successful pregnancy over a period of one year. Additionally, there are limitations to the law for reasons such as age, amount of treatment cycles attempted and the location of facilities need to conform to standards and guidelines set by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility.

As well, the length of coverage must be at least twelve months and disclosure of previous infertility treatments to insurance company must be provided. These reasonable limitations provide both a sense of financial security to the individual seeking treatment and insurance company’s because they limit the possibility of loss. In 2005, the law was amended to provide an exemption for coverage that goes against an employer or individual’s religious beliefs. If this law were enacted in each state, many more individuals would be able to receive help with expenses when going through infertility treatments (“State Laws Related to Insurance Coverage for Infertility Treatment, 2018).

One policy that could be set in place to help provide coverage for infertility treatments deals with employer-sponsored coverage. Sometimes the employer does not have control of which benefits are covered under the insurance plans; however, insurance companies can offer “Infertility Riders” which are small benefits just for IVF or infertility. If the insurance company does this, policies could be put in place that the employer has to then add this to their standard benefits plan and offer the coverage for their employee.

Currently, only nine states have mandates that require coverage for IVF treatments by the employer (“Your Employer and Your Options”, 2019). This option could be cost effective and may not even raise medical costs because according to an employer survey conducted, 91 percent of employers who offer infertility treatment have not seen an increase in those costs as a result of providing such coverage (Mercer, 2006).

The last alternative policy proposed is to follow a program such as Shady Grove’s “Shared Risk 100% Refund Program” which sends 82 percent of families home with a baby and the other 18 percent receives a full refund (“Guarantee Programs”, 2019). This program provides in vitro fertilization, donor eggs, and/ or gestational carrier as long as the individual is qualified. How the Shared Risk program works is that patients can attempt up to a certain amount of IVF or donor egg cycles, which is six, for a flat fee. When a baby is brought home from the hospital, the center has earned the fee; however, if attempts are unsuccessful, patients are refunded 100 percent of the fee.

The eligibility requirements include: a physician medically indicating the proposed treatment, the woman must be 40 years old for IVF cycles, those who do not have insurance benefits, and women who are 41 or older can participate if using donor eggs. These eligibility requirements help lessen the potential risk of loss and can ensure a better outcome for both the center and patients. With more places such as Shady Grove around the country who provide a program like this, more woman and families can try having a baby with less stress because of the fact they will be refunded after failed attempts.

Critique of Policy Alternatives

When deciding on which alternative to choose it is important to consider different aspects and how they will affect, not only the individual but society as a whole as well. With a problem such as lack of insurance coverage for infertility treatments in the United States, one should consider the tradeoffs of all alternatives proposed. Adoption does indeed come with many benefits because both a family and the child find themselves with a family; however, it may not be the perfect solution to a couple who is having trouble having a baby that is biologically theirs.

There is a long process involved with adoption and a substantial amount of stress and/or uncertainty. Additionally, adoption can be expensive with legal costs (find out how much it may cost) so not everyone may be able to afford this alternative to infertility treatments either. Furthermore, with the consistency of one policy, such as the Connecticut law, there will be a lot of administrative costs that come with implementing it. Mandating that infertility treatments are covered by all insurance policies will cost a lot and there is still a chance that the couple does not become pregnant.

With the riders on insurance companies to include infertility coverage, it will be difficult to set national standards on who will be eligible or not for the coverage because insurance policies are all different. Finally, the tradeoffs to programs like the “Shared Risk 100% Refund Program” are that not everyone may have the money to pay upfront for the treatments. This does not necessarily improve coverage for those who are not covered by insurance.

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Infertility Coverage. (2021, Oct 15). Retrieved from