State-by-State Infertility Insurance Coverage
Currently fifteen U.S. states mandate some form of infertility insurance coverage. Coverage varies by state, with some having more requirements and limitations than others. It’s important for you to know what your state requires, if you’re fortunate enough to be in one of those states.
Examples of limitations include:
- Coverage does not include the use donor sperm or eggs
- Coverage only includes certain types of infertility treatments
- Coverage can dictate who performs the treatment and where it’s performed
- Coverage includes limits on how many IVF cycles will be covered
- Coverage may have age cut-offs
- Coverage may be capped at a certain amount
Many states also have a “definition of infertility” that you must meet in order to have coverage.
Religious organizations, self-insured plans and small businesses with few employees, as well as HMOs, are often exempt from having to cover these infertility treatments.
Infertility insurance coverage by state
Below is a summary of infertility insurance coverage by state along with a link to the state’s site for more information.
Arkansas: With the exception of HMOs, all health insurers providing maternity benefits must provide IVF benefits. Infertility treatment benefits are subject to the same deductibles and co-pays as maternity benefits.
California: Insurance companies are not required to provide infertility insurance coverage and employers are able to choose if they will include it in their employee benefits package. California law only requires insurers to inform employers that this coverage is available.
Connecticut: The state of Connecticut requires that individual and group health insurers must cover infertility diagnosis and treatment expenses when it’s medically necessary for patients under the age of 40.
Hawaii: Individual and group health insurers that provide pregnancy-related insurance benefits must also provide a one-time-only benefit for outpatient costs for IVF treatment.
Illinois: Insurers covering more than 25 people and providing maternity benefits must also provide infertility treatment benefits for those who have been unable to get pregnant after one year of unprotected sex or is unable to carry a pregnancy to term.
Louisiana: Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility.
Maryland: Certain insurers providing maternity benefits must also cover outpatient costs of IVF.
Massachusetts: Medically necessary costs of infertility diagnosis and treatment must be covered by HMOs and those insurers that also cover pregnancy-related benefits. Infertility is defined as “the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period.”
Montana: HMOs are required to cover infertility services as part of their basic preventive healthcare services. Infertility services are specifically excluded from the scope of health benefits other non-HMO insurers must provide.
New Jersey: Insurers that provide pregnancy-related benefits must also provide benefits to cover diagnostic and treatment of infertility costs. The state defines infertility as “the disease or condition that results in the inability to carry a pregnancy to term or the inability to get pregnant after two years of unprotected sex for a female partner under the age of 35 or one year of unprotected sex for a female partner over the age of 35.”
New York: Private and group health insurers are prohibited from excluding coverage of hospital, medical or surgical care for the diagnosis and treatment of a correctable medical condition solely because the condition results in infertility.
Ohio: HMOs are required to cover medically necessary, basic preventive health services, which includes infertility.
Rhode Island: Insurers and HMOs providing pregnancy-related benefits must cover infertility diagnostic and treatment costs when medically necessary. Infertility is defined as “the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year.”
Texas: Group insurers who cover pregnancy services must also provide coverage for IVF treatment. Employers are not required to include infertility benefits as part of their employee insurance plans.
West Virginia: HMOs are required to cover basic health care services when medically necessary, including infertility services.
Fear not! If your state is not one of the lucky fifteen, that doesn’t mean you may not have coverage. Many employers in the remaining 35 states still opt to offer infertility health insurance benefits.
The insurance specialist at your fertility clinic will be a terrific resource in helping you maximize any infertility insurance benefits you may have.
Bottom line: no matter where you live, take the time to fully understand your health insurance coverage so you can maximize any benefits you may be entitled to.
Sources: Resolve.org: The National Infertility Association: State Info on Insurance Coverage. American Society of Reproductive Medicine: State Infertility Insurance Laws.
