medical insurance coverage for infertility treatment and IVF, in vitro fertilization can be simple or complicated. this is an effort to explain some of the issues related to health insurance coverage for infertility testing and treatment.
Because our fertility clinic is located in northern illinois and nearby wisconsin, insurance coverage for ivf and infertility in illinois and wisconsin will be specifically addressed. Insurance coverage for infertility, artificial inseminations, and in vitro fertilization varies widely. some insurance plans won’t cover infertility services, some pay for everything, and many fall somewhere in between.
About 15 states have some sort of mandate for infertility insurance coverage, so couples in those states are likely to get some help paying for their fertility services from their health insurance plan.
In states without any infertility coverage mandates, most insurance plans don’t help much with paying for IVF and fertility services. IVF insurance coverage is less common than coverage for fertility services other than IVF. This is because IVF costs more than other infertility tests and treatments.
insurance plans in which we are currently “participating providers”
we can serve patients with any ppo plan. When a doctor is “out of network” it does not mean that the insurance company will not pay for the services. if we are not “in-network” with the plan, then the patient will generally have a higher “coinsurance” amount (what they are expected to pay) compared to going to a doctor who is “in-network” .
We have many patients who see us “out of network”. have decided to come to us “out of network” (and pay more out of pocket) because of our superior success rates, our personalized attention, recommendations from friends or your doctor, or for other reasons.
infertility tests and health insurance coverage
Health insurance plans will usually (but not always) pay for services related to infertility testing. however, many plans say that once the diagnosis has been established, they will no longer pay for fertility-related services. this is probably due to the fact that covering diagnostic tests doesn’t cost them much.
there are possible gray areas with coverage for testing. For example, a woman is trying to get pregnant and has heavy periods and severe menstrual cramps. she has a hysteroscopy at the fertility clinic to investigate the situation. Regardless of the test results, the insurance company may pay it in full or deny payment saying it doesn’t cover infertility. Was the test done because of her bleeding and pain, or was it done for infertility? what if it was done for all those reasons? sometimes it can be a bit tricky and confusing.
infertility treatment and insurance
Infertility treatment is covered by insurance much less often than testing. Outside of a state-mandated situation (see below), when there is coverage for infertility treatment, it is quite common to exclude IVF or have a lifetime maximum benefit.
We commonly see health insurance plans that have between $10,000 and $25,000 lifetime maximum. this limits potential costs to the insurance company. In other cases, insurance will cover testing and treatment up to and including intrauterine inseminations, but will not cover in vitro fertilization (IVF) services. “Follow-up” IVF ovarian stimulation (blood tests and ultrasound) is sometimes covered, but not all (more expensive) IVF codes are covered.
state insurance obligations for IVF and infertility services
There are currently 15 states that have infertility mandates of some kind. the mandates are very different in what is covered: how many ivf cycles etc. some of the mandates are very comprehensive and others much less so. details of non-illinois mandates are not discussed here.
state of illinois insurance mandate for infertility and ivf services
The State of Illinois passed the Family Building Act in 1991. In short, it requires group health insurance plans covering more than 25 employees to cover diagnosis and treatment of infertility for up to 4 IVF attempts (procedures egg retrieval) inclusive.
The following text is from the il department of financial and professional regulation website.
sec 356m infertility coverage.
(a) no group accident and health insurance policy providing coverage for more than 25 employees that provides benefits related to pregnancy may be issued, amended, delivered, or renewed in this state after the effective date of this amendment law of 1991, unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo flushing, embryo transfer, artificial insemination, tubal gamete transfer, fallopian tube, fallopian tube zygote transfer, and lower tube egg transfer.
(b) the coverage required under subsection (a) is subject to the following conditions:
(1) Coverage for in vitro fertilization procedures, intra-fallopian tube gamete transfer, or intra-fallopian tube zygote transfer will be required only if:
(a) the covered person has been unable to achieve or maintain a successful pregnancy through less expensive, reasonable and medically appropriate infertility treatment for which coverage is available under the policy, plan or contract;
(b) the covered person has not undergone 4 complete oocyte retrievals, except that if a live birth follows a complete oocyte retrieval, then 2 more complete oocyte retrievals will be covered; and
(c) procedures are performed in medical facilities that conform to the American College of Obstetrics and Gynecology guidelines for in vitro fertilization clinics or the American Fertility Society minimum standards for in vitro fertilization programs.
(2) The procedures to be covered under this section are not required to be included in any policy or plan issued to a religious institution or organization or to an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this section to violate your religious and moral teachings and beliefs.
(c) For purposes of this section, “infertility” means the inability to conceive after one year of unprotected intercourse or the inability to maintain a successful pregnancy.
(Source: p.a. 89-669, effective 1-1-97.)
more details are available about illinois infertility and ivf insurance. click below for a pdf document of the state of il:
mandatory insurance coverage law for infertility treatments in illinois
gaps in illinois infertility insurance mandate
It may seem like a command should be a command. however, in the case of illinois, someone decided that the il command is “somewhat optional” (my own take on the situation). it has evolved over the years since 1991 so that now (2015) there seem to be some loopholes that allow employers to offer plans without infertility coverage.
This situation exists despite the fact that the law itself has not been repealed or modified. What has changed, perhaps, is the interpretation and enforcement of the existing “infertility mandate.”
Common reasons we hear for why various IL plans don’t cover infertility services at all, or don’t meet IL’s full mandate include:
we have a self-insured plan, so we don’t have to cover infertility our company is based in ________ (fill in the blank, germany, arizona, etc.) our insurance company is based in ________ (wherever ) it’s not our (employer’s) fault, we don’t know why that insurance company doesn’t cover infertility. All of these excuses boil down to, “We don’t want to pay for that, so sue us if you think you can win.” ”. Of course they don’t say that, but it’s still the bottom line. People don’t want to pursue an expensive and possibly losing lawsuit against their employer, so they pay for their fertility services “out of pocket.”
Fortunately, many employers in IL are following the mandate and offering plans that cover mandatory infertility services. however, quite a few do not cover it, or only offer coverage that does not reach the levels established in the mandate.
Over time, more states are passing mandates for infertility insurance coverage. who knows how the situation in illinois will evolve over time. infertility support organizations have also been pushing for a national infertility insurance, so far without success.
In many countries around the world, infertility is considered a disease like any other, and is covered by health insurance or the socialized medical system like any other disease. In the United States, insurers see it more as a social problem than a medical problem, and it can then be added to health insurance plans as an “extra” if desired. in the end, money drives everything.
state of wisconsin infertility and ivf insurance coverage
Because our Gurnee office is close to the Wisconsin border, we have many couples who come to us for IVF treatment. Unfortunately, Wisconsin does not yet have any state mandate to cover IVF or infertility services. some employers will cover it to some extent, but many do not provide any coverage at all.
It is quite common for our Wisconsin patients to have some coverage for diagnostic tests and much less common for them to have any coverage for infertility treatment. about 5% of our wisconsin patients have ivf insurance coverage. hopefully health insurance coverage for infertility and ivf in wi will be more common in the future.
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