Runners receive knee surgery so that they can continue running; breast cancer patients receive reconstructive breast surgery so that they can feel like themselves again; children born with hearing problems receive surgery to improve their hearing.
Celebrity moms and limits of the postpartum depression 'reveal'. Yes, people could manage without these interventions, just like infertile people could manage without children. But should they have to? Infertility can lead to serious depression and anxiety , and the fallout can last a lifetime. Kara N. Goldman, assistant professor of reproductive endocrinology and infertility at New York University who has advocated for comprehensive infertility coverage in New York.
Where the fight for coverage stands. Thankfully, the American health care system is starting to come around. In , the American Medical Association declared infertility a disease.
In the summary of the decision, the association expressed hope that the new designation would "promote insurance coverage and payment" and remove some of the stigma.
This shift was partially due to the lobbying by the American Society for Reproductive Medicine. In recent years, the society has made a strategic effort to ensure that more Americans have access to reproductive medicine. He explained that he and his fellow infertility doctors have become increasingly sensitive to the fact that much of the American population simply can't afford infertility treatment.
There's also a growing concern that, due to financial constraints, patients are making suboptimal decisions about treatment. They are choosing to transfer multiple embryos to the uterus at once, instead of the now-recommended single embryo transfer, in order to avoid paying for more procedures. This leads to a higher risk of complications for mother and child -- and higher long-term health care costs for insurance companies.
The 'breast is best' policy backlash. Advocates from Resolve and the American Society for Reproductive Medicine hope that the American Medical Association's designation will help them get states to pass laws mandating infertility coverage. Nine states require some degree of infertility coverage, some of which offer multiple rounds of IVF, while others only offer less expensive, and less effective, treatments. The most recent state to pass a law was in Delaware, where infertility patient Christie Gross, with the help of Resolve, spearheaded support for one of the most comprehensive bills around.
This includes coverage for infertility treatments, including IVF, as well as fertility preservation for cancer patients. Furthermore, many costs associated with surrogacy are often not covered by insurance. States also vary in which treatment services they require plans to cover. Some states mandate insurers to cover cryopreservation for persons with iatrogenic infertility, while others do not.
Four states with insurer mandates do not cover IVF. Eleven states do, but with a dollar limit on coverage e. Similarly, a national study found that IVF availability and utilization 9 were significantly higher in states with mandated IVF coverage. A study in MA found IVF utilization increased after implementation of their IVF mandate, but overutilization by patients with a low chance of pregnancy success was not found. State level mandates can also help reduce inequities in access.
For example, a recent bill proposed in the CA legislature would reverse existing limitations on fertility coverage and make the benefit available to single women and women in same sex relationships. While the costs of fertility treatments can be very expensive for those who lack coverage, the cost of covering fertility benefits varies depending on the services covered and utilization with implications for state budgets, employers, and policy holders.
For example, in , New York passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies. Overall though, out of pocket spending for individuals seeking services would decrease substantially. In , California was considering a more limited bill that would require fertility preservation for iatrogenic infertility in certain individual and group health plans.
While these costs could be modest in comparison to the costs of paying out-of-pocket for these services, there are other costs to coverage mandates. The ACA requires states to offset some of the costs for any state mandated benefits beyond essential health benefits EHBs in the individual and small group market. Large employers are more likely than smaller employers to include fertility benefits in their employer-sponsored health plans.
Coverage is higher for diagnostic evaluations and fertility drugs. Coverage is more common among the largest employers and those that offer higher wages Figure 5. NSFG data show that significantly fewer women with Medicaid have ever used medical services to help become pregnant compared to women with private insurance. As of January , our analysis of Medicaid policies and benefits reveal only one state, New York , specifically requires their Medicaid program to cover fertility treatment limited to 3 cycles of fertility drugs Figure 6.
However, some states may require Medicaid to cover treatments for conditions that impact fertility, while not directly stated in their policies. For example, states may cover thyroid medications, or cover surgery for fibroids, endometriosis or other gynecologic abnormalities if causing pelvic pain, abnormal bleeding or another medical problem, other than infertility. For example, New York Medicaid specifically covers office visits, HSGs, pelvic ultrasounds and blood tests for infertility.
Meanwhile, the infertility assessment covered by Georgia Medicaid includes lab testing, but not imaging or procedural diagnostics. Others do not mention infertility diagnostics in their Medicaid policies, meaning the beneficiary would need to check with their Medicaid program to see if these services are covered Appendix 2. Because eligibility for Medicaid is based on being low-income, people enrolled in the program likely could not afford to pay for services out of pocket.
The relative lack of Medicaid coverage for fertility services stands in stark contrast to Medicaid coverage for maternity care and family planning services. Nearly half of births in the U. Therefore, while there is broad coverage of many services for low-income people during pregnancy and to help prevent pregnancy, there is almost no access to help low-income people achieve pregnancy. Diagnostic services are covered, including lab testing, genetic testing, and semen analysis.
Treatment to correct physical causes of infertility are also covered. Veterans Affairs VA : Infertility services are covered by the VA medical benefits package, if infertility resulted from a service-connected condition. This includes infertility counseling, blood tests, genetic counseling, semen analysis, ultrasound imaging, surgery, medications and IVF as of However, the couple seeking services must be legally married, and the egg and sperm must come from said couple effectively excluding same sex couples.
Family planning providers are recommended to provide at minimum patient education about fertility and lifestyle modifications, a thorough medical history and physical exam, semen analysis, and if indicated, referrals for lab testing of hormone levels, additional diagnostic tests endometrial biopsy, ultrasound, HSG, laparoscopy and prescription of medications to promote fertility.
Before I could rattle off the next lab result in her chart, she immediately burst into tears. I grabbed a box of tissues and quickly passed them to the sobbing woman across from me. This was not the reaction I had been expecting. What my patient was struggling with was infertility. Infertility is a disease of the reproductive system characterized by the failure to become pregnant after 12 months of regular unprotected sex, and it affects 1 in 8 couples in the United States.
The bad news is that, without insurance coverage, some of these treatments are prohibitively expensive. Infertility is a disabling medical condition , and it can significantly reduce quality of life. One might debate this, saying there is a difference between access and insurance coverage. While I agree that a difference does exist, I would respond that affordability is encompassed within accessibility, and offering insurance coverage is one method of increasing the affordability of, and therefore access to, treatment.
Hawaii Rev. In order to qualify for in vitro fertilization procedures, the couple must have a history of infertility for at least five years or prove that the infertility is a result of a specified medical condition. Coverage includes in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete sperm artificial intrafallopian tube transfer, zygote intrafallopian tube transfer and low tubal ovum transfer.
Coverage is limited to four completed oocyte retrievals, except if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals are covered. Laws, P. The law does not require insurers to cover fertility drugs, in vitro fertilization or other assisted reproductive techniques, reversal of a tubal litigation, a vasectomy, or any other method of sterilization.
Acts, P. Insurance Code Ann. The law clarifies the conditions under which services must be provided, including a history of infertility of at least a 2-year period and infertility associated with one of several listed medical conditions. The law clarifies that an insurer or employer may exclude the coverage if it conflicts with the religious beliefs and practices of a religious organization, on request of the religious organization.
Regulations that became effective in exempt businesses with 50 or fewer employees from having to provide the IVF coverage. Laws, Chap. Health General Code Ann. Laws Ann. This law was amended in to change the definition of "infertility" to be a condition of an individual who is unable to conceive or produce conception during a period of one year if the female is under the age of 35, or during a period of six months if the female is over the age of If a person conceives but cannot carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the one year or six month period.
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