Health insurance for fertility

Health insurance for fertility is a policy category that covers diagnostic tests and treatments for infertility, such as in vitro fertilization (IVF), intrauterine insemination (IUI), and fertility medications. Federal law does not require coverage for fertility services, but 21 states, including Illinois and Massachusetts, mandate some form of infertility insurance coverage.

Most employer-sponsored plans exclude IVF coverage, with only about 27% of firms offering any fertility benefits as of 2021. Policies often limit the number of IVF cycles covered, with common limits set at two or three cycles per lifetime.

Insurers frequently require proof of infertility after 12 months of unprotected intercourse before approving treatment claims, as specified by the Insurance Information Database. Fertility drug coverage varies; Clomid is usually covered while gonadotropins are often excluded unless mandated by state law.

Preauthorization is necessary for most advanced procedures such as egg freezing or donor egg use, which only six states require insurers to cover. Medicaid excludes coverage for most fertility treatments except basic diagnostic testing in a few states like New York and New Jersey.

Out-of-pocket costs average $12,400 per IVF cycle in the US when insurance denies coverage. Insurers may deny claims if the policyholder has had voluntary sterilization without documented medical necessity reversal efforts.

Appeals processes exist, but success rates are low–less than 10% based on insurer records such as those from UnitedHealthcare and Aetna.