Key Points
- A lot of people need fertility help to achieve a pregnancy, including men and women with fertility issues, LGBTQ people, and single persons who want to have their own babies. Around 10% of women say they or their spouses have ever gotten medical assistance to conceive.
- Even though a lot of people need reproductive services, fertility care is out of many people’s reach because of the high cost. Most public or private insurers don’t cover fertility services. Although 15 American states require that private insurance providers cover some fertility treatment, there are huge gaps in the coverage offered. Just one state has insurance that covers fertility treatments, and no state Medicaid program covers IVF (in vitro fertilization) or IUI (artificial insemination).
- Patients usually have to pay for fertility treatment out of pocket, which can cost them more than $20,000 based on the services received. This implies that a lot of people will not be able to access fertility care without health insurance coverage.
- Fewer Hispanic and Black women say they have ever used medical services to conceive compared to White women. This may be due to several factors, such as lower average incomes among Hispanic and Black women, as well as barriers and myths deterring women from getting fertility assistance.
- LGBTQ people encounter more challenges accessing reproductive care since they don’t usually meet the definitions of “infertility,” which could make them eligible for covered fertility services. Trans people going through gender-affirming therapy may also not fulfill the requirements for “iatrogenic infertility,” which would make them eligible for covered fertility preservation.
Introduction
A lot of people need fertility assistance to become parents, whether due to infertility diagnosis or because they are in a same-sex relationship or without a partner and want to have children. Although there are different kinds of fertility assistance, fertility services are inaccessible for many individuals due to the cost.
Fertility treatments are costly and are not usually covered by insurance. Even though some private insurance plans provide coverage for infertility diagnostic services, there is little coverage for fertility treatment options like IVF and IUI, which are pricier.
The majority of individuals who use fertility services have to pay from their own pocket, with costs sometimes shooting up to thousands of dollars.
Only a few states require that private insurers cover infertility services, and just one state requires that Medicare (a public insurance program for low-income individuals and families) provide infertility coverage. This increases the gap for people who earn low incomes, even when they have insurance coverage.
In this piece, we will look at how access to fertility services varies in the United States, depending on income level, insurance type, state laws, and patient demographics.
Fertility Diagnosis and Treatment Services
Infertility is often defined as the inability to become pregnant after 1 year of having regular sexual intercourse without protection. It affects around 10-15% of heterosexual couples. Both male and female factors can lead to infertility, such as structural issues with the fallopian tubes or womb, problems with ovulation (the release of eggs from the ovary), hormonal factors, etc.
In 25% of cases, infertility is due to two or more factors, and in around 10% of cases, there is no explanation for infertility. However, infertility estimates do not consider singles or LGBTQ people who may also require fertility help to build a family. That said, there are different reasons why people may pursue fertility care.
A wide range of diagnostic and treatment services may be required to help with fertility. Diagnostics may include laboratory tests, a semen analysis, as well as imaging procedures or examinations of the reproductive structures. If a likely cause of infertility is found, treatment is usually aimed at addressing the root of the issue.
For instance, thyroid medications may be prescribed for someone with abnormal thyroid hormone levels to help them conceive. And if a patient has fibroids in her womb cavity, surgical removal of these usual growths can make future pregnancy possible.
At times, other medical interventions may be required to help patients conceive. For instance, if a semen analysis indicates poor sperm motility in the male partner or the fallopian tubes are obstructed, it will be impossible for sperm to fertilize the egg. In this case, IVF (in vitro fertilization) or IUI (intrauterine insemination) may be needed. These fertility procedures can also help LGBTQ individuals and single people build a family using donor sperm or eggs, with or without the assistance of a Surrogate (surrogacy).
Use of Fertility Services
An analysis of 2015-2017 National Survey of Family Growth data shows that 10% of women of reproductive ages report that they or their spouse have once spoken to a physician about ways to help them conceive. However, the most common service these women reported is fertility advice.
According to the Centers for Disease Control and Prevention (CDC), the use of IVF has significantly increased since the first American “test-tube” baby was born in 1981. Recent data shows that around 1.8% of US babies are conceived every year through assisted reproductive technologies, such as IVF and other ART procedures.
The numbers of IVF-born babies are highest in the Northeastern states ((CN 3.9%, NJ 3.9%, MA 4.7%) and lowest in the Southern and Southwestern states (NM 0.4%, MS 0.6%, AR 0.6%).
Generally, the use of fertility services has reduced significantly during the coronavirus public health emergency. In March 2020, the American Society for Reproductive Medicine (ASRM) dished out guidelines to halt new fertility treatment cycles and diagnostic procedures that are not urgent. ASRM has since offered new guidance regarding the conditions to be met and the measures that must be taken before restarting fertility care.
A study conducted by Strata Decision Technology of 228 clinics indicated that patient encounters for infertility services reduced by 83% from March 22-April 4, 2020, compared to this period the year before.
Cost of Services
A lot of patients do not have access to fertility services, mostly because of its expensive cost and little to no coverage by Medicaid and private insurance program. Consequently, many individuals who use medical services to conceive have to pay from their own pocket even though they have insurance.
The costs of out-of-pocket payment vary based on the patient, state of residence, insurer, and insurance plan.
Usually, diagnostic lab tests, ultrasounds, and semen analysis are cheaper than diagnostic procedures, like surgery (e.g., laparoscopy, hysteroscopy) or hysterosalpingography (HSG).
Although treatment using fertility drugs is more affordable than IVF and IUI, even less expensive treatments can still cost you thousands of dollars from your own pocket. Most patients need to undergo several treatments before they or their spouse become pregnant (usually medication first and then surgery or fertility procedures if the drugs failed to yield results).
A study of about 400 women receiving fertility care in Northern California shows this is the common trend, with treatment using medication alone having the lowest out-of-pocket costs, while IVF services have the highest cost. Past studies indicated that one standard IVF cycle used to cost about $12,500 in 2019, but the price is probably higher nowadays because of the increasing cost of health care generally.
Moreover, patients usually need to undergo multiple treatment cycles before becoming pregnant, with costs piling up with each cycle, making these medical services financially out of reach for many individuals. Aside from the actual treatment costs, patients may be responsible for out-of-pocket fees for diagnostic tests/procedures, clinic visits, use of donor egg/sperm, genetic testing, as well as storage fees, and lost wages.
Thankfully, some fertility clinics do offer special affordable prices for fertility treatments in order to make fertility care accessible to a wider section of the populace.
Insurance Coverage
Insurance coverage differs based on the state the person resides in and the size of the employer for those with employer-provided insurance.
Insurance companies don’t consider a lot of fertility treatments “medically necessary,” so they are not usually covered by Medicaid programs or private insurance plans. Even when there is coverage, some types of fertility services (i.e., diagnostic testing) are more likely to be covered by insurance compared to others (i.e., IVF).
Only a few states require infertility coverage for certain fully insured private plans, which are controlled by the state. However, these requirements are not applicable to employer-funded insurance plans, which cover about 61% of workers using employer-sponsored insurance.
Plus, states have control over the benefits offered in their Medicaid programs, while the federal government possesses some power regarding the requirement for benefits in their health insurance programs, like Medicare, military health coverage, and the Indian Health Services.
Private Insurance
15 US states have laws that require certain health plans to cover infertility treatments. Moreover, Colorado just passed a law requiring that individual and group health insurance plans provide coverage for diagnosis, treatment, and cryopreservation for iatrogenic infertility, starting from January 2022.
9 out of these states without a “mandate to cover” and Washington DC have an EHB benchmark plan, which covers at least some infertility services (i.e., diagnosis and possibly treatment) for the majority of individual and small group insurance plans offered in that state.
2 American states (Texas and California) require that group health benefit plans have a policy (at least) that covers infertility treatments. However, employers do not have to select these plans.
In states with laws mandating insurers to cover infertility services, these apply to certain insurance providers, for some treatment services, and for some type of patients. Some states even have monetary limits regarding costs that should be covered. For instance, in West Virginia and Ohio, only health maintenance organizations are required to cover infertility services.
In other states, nearly all HMOs and Insurance providers have a mandate to cover infertility treatments. A lot of states exempt small employers (with less than 50 workers) or religious employers from infertility coverage. Moreover, state laws are not applicable to self-funded employer plans, which are under federal law. 61% of workers with insurance are covered in a self-insured plan.
Even in states that have infertility coverage laws, not every patient qualifies for treatment services. For example, in Hawaii, patients with unexplained infertility are only eligible for IVF after experiencing infertility for 5 years. Meanwhile, in other states, they are qualified after just one year.
Some US states have age restrictions on female patients who can make use of these services (e.g., you don’t qualify if you are 46 or above in New Jersey or if you are below 25 or more than 42 in Rhode Island).
Other states put restrictions based on the patient’s marital status. For instance, until May 2020, only married women could use IVF services in Maryland. The state just passed legislation extending infertility coverage to women who are not married. Also, it is often unclear whether or not LGBTQ people qualify for these benefits if they are not diagnosed with infertility. Besides, insurance does not usually cover many costs involved in surrogacy.
States also differ regarding treatment services covered by their health insurance plans. While some states require that insurance providers cover fertility preservation for people with iatrogenic infertility, other states do not.
Only 4 states with insurer mandates don’t provide coverage for IVF. 11 states offer coverage, but there is a dollar limit on infertility coverage (e.g., a maximum of $15,000 in Arizona and $100,000 in Rhode Island and Maryland) or a cap on the number IVF cycle that will be covered (e.g., a single round of IVF in Hawaii and three IVF rounds in New York).
Do State Mandates on IVF Coverage Have Any Effect on the Use of Fertility Services?
IVF use seems to be higher in states that have mandates for IVF coverage.
2016 data from the CDC indicated that the use of IVF was 1.5X higher in 3 of the 4 states considered to have comprehensive IVF coverage by the CDC. A national study also showed that IVF services were more used and more available in states with IVF coverage mandates. A 1998 study conducted in Massachusetts found that the use of IVF went up after their IVF mandate was implemented, but there was no overuse of the service by patients with a slim chance of pregnancy.
State IVF mandates can go a long way in helping to lower inequities in access to fertility care. For instance, California lawmakers have recently proposed a bill that would remove present restrictions on fertility coverage in the state and make the benefit accessible to women who are single or in a homosexual relationship.
What Does It Cost to Offer Fertility Benefits?
Although the fertility treatment costs can be too high for individuals without coverage, the cost of providing fertility benefits differs based on the type of services covered and usage, with huge implications for employers, policyholders, and state budgets.
For instance, in 2019, New York approved a bill requiring that comprehensive private health policies cover IVF and fertility preservation services. The state’s Department of Financial Services claimed mandating IVF coverage would increase premiums by around 0.5 – 1.1% and by 0.02% for providing fertility preservation in the case of iatrogenic infertility.
A 2020 analysis of the California bill requiring private insurance plans and Medi-Cal plans to offer IVF coverage showed that monthly premiums would go up by around $5 in the private market and below $1.00 for Medi-Cal care plans. However, out-of-pocket expenses would significantly reduce for people pursuing fertility services.
Data from Connecticut, Maryland, and Rhode Island indicate that mandating infertility coverage does not seem to significantly increase premiums. These states have been mandating infertility benefits for more than 3 decades, and the estimated cost of infertility coverage is not up to 1% of overall premium costs.
In 2017, the California legislature was working on a bill that would mandate fertility preservation for iatrogenic infertility (infertility caused by medical treatment) in some individual and group health insurance plans. The introduction of the bill was said to increase the annual premium costs by $2,197,000 or 0.0015% for those who are enrolled in plans subject to the IVF mandate.
Although these costs might look modest compared to the costs of paying for these services out of pocket, there are many other costs associated with coverage mandates. The affordable care act (ACA) requires that states cover some of the costs for their mandated benefits above EHBs in the small group and individual markets. This was expected to cost New York around $59-69 million every year if covering a single cycle or $98-116 million yearly if there are no limits to the numbers of IVF cycles covered.
What Percentage of Employers Provide Fertility Benefits?
Large corporate employers are more likely to offer fertility benefits in their insurance health plans compared to smaller employers.
As per Mercer’s National Survey of Employer-Sponsored Health Plans, 56% of employers with more than 500 workers offer some kind of fertility coverage, although most do provide coverage for treatment services like IUI, IVF, or egg cryopreservation. There is higher coverage for diagnostic tests and fertility medications, and infertility coverage is more prevalent amongst the biggest employers and those that pay higher wages.
Public Coverage
Medicaid
Data from the National Survey of Family Growth (NSFG) indicate that fewer women covered by Medicaid have ever utilized medical services to help conceive compared to those covered by private insurance. An analysis of Medicaid plans and benefits showed that just one state (NY) has laws requiring their Medicaid program to cover fertility services (maximum of 3 cycles of fertility medications).
Some states may cover treatments for conditions that affect fertility, although this may not be clearly stated in their insurance policies. For instance, states may provide coverage for thyroid drugs or surgery for endometriosis, fibroids, or other gynecological issues if they are resulting in abnormal bleeding, pelvic pain, or another health issue aside from infertility.
Presently, there is no state whose Medicaid program covers IVF, IUI (artificial insemination), or egg /sperm freezing.
Some states provide coverage for infertility diagnostic services. Hawaii, New York, Michigan, Massachusetts, Minnesota, New Hampshire, and New Mexico all have at least one insurance plan with this benefit.
However, the range of diagnostic services covered by insurance differs. While New York Medicaid covers clinic visits, blood tests, HSGs, and pelvic ultrasounds, Georgia Medicaid only covers laboratory testing for infertility, but not procedural or imaging diagnostics.
Other states do not offer coverage for infertility diagnostics or, more broadly, infertility services, which may include diagnostics. Some states do not discuss infertility diagnostics in their policies, so policyholders would have to verify with their Medicaid program to find out if diagnostic services are covered.
The lack of infertility coverage in the Medicaid program has a more significant impact on women of color than White women. Among US women aged 18– 49, the Medicaid program covers 30% of black women and 26% of Hispanic women compared to 15% of White women. Since Medicare is for low-income earners, people covered by this program may not be able to pay for fertility services from their own pocket.
Medicaid’s lack of coverage for fertility treatments is in contrast to its coverage for family planning services and maternity care. Approximately 50% of births in the United States are funded by Medicaid.
The health insurance program also finances most of the publicly-funded family planning services. So, although there is wide coverage of services for low-income earners to help avoid pregnancy and during pregnancy, there is little access to help those on low incomes conceive.
Medicare
Even though the majority of Medicare users are older than 65, Medicare also offers health insurance to about 2.5 million people of reproductive age living with permanent disabilities. Medicare states in its Benefit policy manual that it covers “reasonable and necessary services” linked with infertility treatment. However, the covered services are not specifically mentioned, and fertility services that can be considered “reasonable and necessary” were not clearly defined.
Military
TRICARE, the US military’s health insurance program, will provide coverage for some infertility services if they are considered “medically necessary” and if the conception takes place naturally, meaning that fertilization happens via intercourse between opposite sexes.
This program covers diagnostic services, including semen analysis, laboratory testing, and genetic testing. It also provides coverage for treatment to rectify the physical causes of infertility. However, IVF, IUI (artificial insemination), cryopreservation, and donor eggs/sperm are not usually covered except if the service member’s infertility is due to an injury suffered while on active duty.
Veterans Affairs (VA): VA medical benefits package covers infertility services if the condition is caused by a problem that occurred during military service. The services covered include blood tests, semen analysis, ultrasounds, genetic counseling, infertility counseling, medications, surgery, and IVF. But the couple pursuing infertility services needs to be legally wedded and use their eggs and sperm (making same-sex couples ineligible).
There is no coverage for surrogacy, obstetrical care, or donor eggs/sperm for non-Veteran couples.
Infertility Services in Publicly Funded Clinics
The Centers for Disease Control and Prevention talks about the provision of basic infertility services in its recommendations for Quality Family Planning. Those who offer family planning services are advised to at least educate patients about fertility and lifestyle changes and provide a comprehensive medical history and physical examination, semen analysis, and maybe referrals for laboratory testing of hormone levels, other diagnostic tests, and prescriptions of fertility medications.
But studies of public-funded clinics have shown that infertility services are not evenly available. In a study of over 1600 public-funded family planning clinics, a high percentage said that they offer preconception care (69% for men and 94% for women), but the percentage of clinics that provided basic infertility services (45% for men and 66% for women) is lower.
Provision of infertility treatments, like IVF or IUI, was very rare (16% of clinics) since these services may require referrals to fertility experts who may not accept patients with Medicaid or without insurance. Most of the patients who use publicly-funded clinics earn low income and may be unable to pay for infertility services and treatments when diagnosed.
According to the Indian Health Services Manual for healthcare providers, men and women who use IHS facilities should have access to basic infertility diagnostics. This includes a medical history, semen analysis, physical examination, progesterone testing, and basal temperature charting (to know when ovulation will occur). Diagnostic laparoscopy, endometrial biopsy, and HSG should also be offered in facilities with obstetricians/gynecologists. However, it’s not clear how accessible these services actually are, and it’s not mentioned whether or not infertility treatment should be provided.
Key Populations
Racial & ethnic minorities
The right to have and care for the family you desire is one of the basic tenets of reproductive justice. This includes access to infertility services for people who need them. The percentage of ethnic and racial minorities who use medical services to achieve pregnancy is lesser compared to that of White women of non-Hispanic origin, even though studies have shown that infertility is more common among women of color (Blacks and American Indians).
An analysis of 2015-2017 NSFG data indicates that although 13% of non-Hispanic White women said they have ever seen a healthcare provider for fertility help, only 6% of Hispanic women and 7% of non-Hispanic women did the same.
A larger percentage of Hispanic and Black women are without insurance or covered by Medicaid compared to White women. A wide range of factors can impact access to infertility care, such as income, availability of services, differences in coverage, etc.
Other societal factors also play an important role. Stereotypes and myths surrounding fertility have usually depicted Black women as not needing medical assistance to get pregnant. Due to the history of discriminatory fertility care and harm suffered by women of color in the past decades, some women may postpone pursuing infertility care or decide not to pursue it at all.
Other studies have shown that the use of fertility diagnostic services and treatment also differs among races. An analysis of data from NSFG indicated that among women who said they have used medical services to conceive, similar percentages of White (75%), Black (69%), and Hispanic (70%) women got fertility advice.
However, just 45% of women who reported using medical services to achieve pregnancy said they underwent tests for infertility compared to 62% of White women, and fewer colored women got treatment services. An analysis of ART surveillance data showed that IVF use is highest among White and Asian women and lowest among American Indian/Alaska Native women.
There may also be racial inequities in fertility preservation too. A study conducted on female cancer patients in New York found that fewer Hispanic and Black patients have their eggs frozen compared to White patients.
A higher percentage of Hispanic, Black, and American Indian people are living below the poverty line compared to White people or those of Pacific Islander or Asian origin. Due to the expensive cost and limited infertility coverage, fertility care is out of reach for many colored individuals who may want to preserve their fertility but cannot afford to do so.
Iatrogenic Infertility
Iatrogenic infertility, otherwise known as medically induced infertility, is when an individual is unable to bear children due to a medical procedure conducted to resolve another issue, i.e., radiotherapy or chemotherapy for cancer.
In cases like this, people of reproductive age who may want to have children later can decide to freeze their sperm/eggs for future use. The ASRM (American Society for Reproductive Medicine) implores clinicians to tell their patients about fertility preservation options before commencing treatment that can cause iatrogenic infertility.
However, the cost of retrieving and freezing sperm or eggs can make fertility preservation inaccessible to many, especially when they are not covered by insurance. Just a few American states (NY, NJ, NH, RI, MD, IL, DE, and CT) have laws requiring private insurance providers to cover fertility preservation in the event of iatrogenic infertility. At present, there is no state offering fertility preservation in their Medicaid insurance plans.
LGBTQ populations
LGBTQ individuals may encounter more challenges when seeking fertility care and discrimination because of their sexual orientation or the gender they identify with. Although section 1557 of the Affordable Care Act forbids discrimination of patients in the health care sector on the basis of their sex, the past government administration has removed these protections with regulatory adjustments.
In the absence of protections that have been eliminated in the present rules, LGBTQ people may not be offered health care, including reproductive care, based on religious freedom laws and proposed adjustments to the Affordable Care Act. However, there are court cases challenging these adjustments because they are in contrast with a Supreme Court decision which states that federal civil rights law forbids discrimination based on gender identity and social orientation.
The American Society for Reproductive Medicine (ASRM) claimed that it is the ethical responsibility of fertility programs to accept and treat LGBTQ people the same way opposite-sex couples would be treated.
The association said that assisted reproductive therapy must not be limited based on gender identity or sexual orientation and that fertility preservation should be provided for transgender men and women prior to gender transitions. This will enable transgender people to have genetically related children later in the future if they want.
In spite of the ASRM recommendation, it is still not clear whether the fertility preservation benefit is extended to transgender people who can become infertile due to their gender-reaffirming care in states with mandated fertility preservation coverage for iatrogenic infertility.
Moreover, a lot of state laws concerning infertility treatment mandates have conditions that can exclude LGBTQ individuals. For instance, in some states like Texas, Hawaii, and Arkansas, IVF services have to make use of the couple’s own sperm and egg (not a donor’s), making same-sex couples ineligible for the services.
In others, homosexual couples don’t meet the standard definition of “infertility” and therefore cannot use these fertility services. There is a lack of data to know the percentage of LGBTQ people who may be allowed to use medical services to help achieve pregnancy. Studies on family building don’t usually consider the fertility needs of LGBTQ people.
Single Parents
Single individuals are not usually provided access to infertility treatment. For instance, the IVF laws requiring that couples use their own eggs and sperm also exclude single persons since they are not allowed to use a donor.
Moreover, some grants and other fertility financing options also state that funds should be given to married couples, excluding singles or couples who are not married. This is in contrast with the opinion of the ASRM committee that fertility programs should provide their services to unmarried couples and single individuals without discriminating against them because of their marital status.
Final Word
Efforts to enact laws that will require insurers to offer fertility service coverage have stopped on a federal level. The Access to Infertility Treatment and Care Act that would require each health plan sold on individual and group markets (TRICARE, VA, Medicaid, etc.) to cover infertility treatment is still being discussed.
Fortunately, we have seen more movement on the state level.
In some states, private insurers are required to provide coverage for infertility services (one of the latest states being New Hampshire in 2020). New York is presently the first and only state whose Medicaid program provides coverage for any fertility treatment.
Getting fertility care can be a very difficult process for people who want to have children. And the stigma surrounding infertility, and complex and sometimes painful treatment procedures can have a severe effect on anyone.
Moreover, the lack of insurance coverage and infertility care cost can be prohibitive for a lot of people, especially low-income earners. Fertility services, such as IVF and fertility preservation, can also be inaccessible to many due to the expensive cost. There are wide disparities in access to infertility services across the US, based on insurance plan, income level, ethnicity/race, gender identity, sexual orientations, and state the individual lives in. To achieve higher equity in access to fertile care, the needs of low-income people, LGBTQ individuals, and people of color have to be addressed infertility policy and coverage.
RSMC has always believed that fertility care should be accessible to everyone irrespective of their reproductive history, race/ethnicity, sexual orientation, or gender preferences. We have long advocated for patients in the hopes insurance policies and laws are structured to benefit everyone needing fertility care. Given the current lack of coverage, RSMC launched an initiative to offer self-paying patients an affordable IVF with embryo transfer package and egg freezing package. Our financial counsellors can be very helpful in reviewing your insurance policy to help you determine if you have coverage for fertility treatment, and if not, they can offset the costs with one of these appraoches. Schedule a consultation and bring your insurance card to see how we can help.
