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February 22, 2023
Embarking on fertility treatment can seem like learning a whole new language. And on top of that, there are alarming costs that can seem daunting when you first see them. One of the first questions that might pop into your head is, “Does my insurance cover IVF?” This article will explain the ins and outs of insurance coverage for fertility care and fertility coverage by state.
This question isn’t so straightforward. It varies depending on the state you live in and the size of your employer if you have employer-sponsored insurance. There are different levels of insurance coverage — some will cover “diagnosis,” some will cover treatment, and some will cover elective fertility preservation.
The best place to start is to ring your insurance company directly and ask if they cover fertility care. If the answer is yes, then get specific answers by asking questions such as:
If you already know what type of fertility treatments you may need — pre-implantation genetic testing, cryopreservation, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), etc. — then ask about them specifically. Find out the best way to track your approvals and denials and how you communicate with your insurance company through the process.
With regards to state coverage, according to RESOLVE: The National Infertility Association, 20 states currently have fertility insurance coverage laws of some kind. These vary from state to state, with some including IVF coverage and some offering fertility preservation laws for iatrogenic (medically-induced) infertility. Let’s break this down into a little more detail.
If you have questions about insurance laws in your state or territory, you can call your territory’s insurance commissioner’s office to get more details.
RESOLVE has a thorough “Insurance Coverage by State” article laying out all the details you need to know here.
A few practical details to know are:
To find out if you are covered by state law, you will need to ask your employer if your plan is:
TRICARE provides limited fertility care. It’s telling that TRICARE refers to fertility health care as “assisted reproductive services.” The services must be medically necessary and combined with coital conception, as described here.
John Crowley, Head of Military Affairs at Legacy, explained there are several issues with TRICARE’s current approach to fertility care.
First and foremost, Crowley discussed that the services covered are reactive instead of proactive. For example, a military service member may be eligible for fertility care after they’ve been seriously wounded in combat or injured in training. Unfortunately, requesting care post-injury is only the first bureaucratic hurdle.
Next, the service member must make the case that their fertility has been compromised with respect to an incomplete (and anachronistic) means of family building and coital conception. According to the Centers for Disease Control and Prevention (CDC), infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex.
For the majority of military families, this 12-month timeline is disrupted by FTXs (field training exercises), CTC (Combat Training Center) rotations, PCS (permanent change of station) moves, and overseas deployments. Ironically, those who are most at risk — special operators — are the least likely to have a 12-month window of opportunity for coital conception with their spouses due to frequent training and deployment. Needless to say, LGBTQ+ service members are completely excluded from fertility care because they are unable to engage in coital conception.
Hypothetically, if a military service member could satisfy TRICARE’s requirements for fertility care, they may be eligible for a semen analysis or a hormone evaluation — that’s it. Assisted reproductive technologies such as IVF and intrauterine insemination (IUI) are not covered. Fertility preservation is not covered. However, if a military service member was injured while serving on active duty, they may be eligible for the following: sperm retrieval, egg retrieval, IVF, artificial insemination, blastocyst implantation, cryopreservation, and storage of embryos (but not gametes).
“We believe Legacy is a private-sector solution to a public-sector problem. We offer fertility products and services to military and veteran communities through various channels, most of which are summarized on our website,” explained Crowley. He went on to advise how Legacy supports military members seeking fertility care:
Fertility benefits programs are separate from your traditional insurance policies. They are additional coverage plans that might bridge the gap in fertility coverage in traditional insurance contracts.
Fertility benefits programs might offer specific coverage, discounts, or funds for fertility care, such as diagnostic tests, infertility treatment, and fertility preservation (like sperm freezing).
To find out if you have access to fertility benefits, talk to your employer. Examples of fertility benefits providers include:
Jennifer O’Brien, M.D., Legacy’s medical billing specialist, answered a few FAQs about fertility coverage.
“Most insurers will cover semen analysis, and many cover storage,” said O’Brien, “but you have to choose a plan that includes fertility benefits.” She explained that every employee should ask their employer to include some kind of benefits for fertility — if not traditional insurance, then fertility benefits providers.
O’Brien confirmed that Legacy does participate with insurance: “We are currently contracted and in network with some United, Aetna, Cigna, Emblem, and TriWest plans. As mentioned above, coverage will vary based on employer offerings, but we are part of their packages in some states,” she advised.
“Yes,” said O’Brien. “HSA/FSA will cover fertility benefits, including ‘temporary storage’ of sperm.”
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