Know your fertility insurance coverage

As you navigate your fertility journey, insurance coverage may be on your mind—what’s covered, what’s not, and what your treatment may cost. And the more you know about your coverage, the better you can plan for treatment. So, let’s break down some of that information here.

First things first: state-mandated fertility coverage

The state in which you work can make all the difference when it comes to covering
fertility treatments. If your state mandates fertility coverage, that means some or all insurance
providers are required to offer insurance benefits for fertility treatments.

As of 2019, 16 states have fertility
insurance coverage laws.
These laws, or mandates, include a mandate to cover
and a mandate to offer.

*Required by HMO only; other insurers are exempt.

Map showing overview of fertility laws Map showing overview of fertility laws

Mandate to cover means that some or all insurance plans have to cover certain fertility treatments.

Mandate to offer means that while insurance providers have to offer certain testing and treatment services, employers can decide which of those benefits, if any, to offer to people covered by their plan.

What happens when you live in one state and work in another?

Great question! Generally, the state where your employer is located determines whether or not the state mandate applies to your employer-provided health insurance plan. So, if you live in Pennsylvania, work for a company in New Jersey, and are covered by that company’s insurance, you may have coverage for fertility treatment under New Jersey’s state mandate.

If you work in 1 of these 16 states, it's more likely
that your fertility treatment may be covered.

Talk to the financial specialist at your reproductive endocrinologist’s (RE) office
to find out what’s covered and how much you may need to pay out of pocket. And if
your RE doesn’t have a financial specialist on staff, call your insurance benefits provider. Here are 10 questions that can help you get the answers you need.

Do you know what type of health insurance you have?

The type of health insurance you have can make a difference in the coverage you
can get. Most people are covered by group insurance policies, which can be public
or private. However, some types of insurance are exempt from state mandates.

Public insurance

Public insurance includes government programs like Veterans Administration for people who’ve served in the armed forces and TRICARE, which covers current military personnel and their families.

There are no federal mandates that require public insurance to cover infertility. You should talk to your benefits
provider to find out what services are covered for you.

Private insurance

Private insurance includes commercial insurance companies, like Aetna and Cigna, among others; nonprofit insurance companies, like Blue Cross/Blue Shield; and self-insuring groups, like employers who pay benefit claims directly instead of using an external insurance provider.

Self-insuring businesses are exempt from state mandates to provide or offer coverage. So, if your employer is
self-insured, you should check with your HR representative or benefits manager to find out what’s covered for you.

Insurance jargon can be hard to follow, which is why we put
together this list of some of the words and phrases you might come
across and what they mean
.

Your insurance provider covers fertility treatment.
What now?

So, your or your partner’s employer-provided insurance covers some fertility testing and treatment—that’s great!
Your next steps should be finding out what’s covered, what’s not, and how much you may have to pay. The best
person to help you figure that out is the financial specialist at your RE’s office or your insurance benefits provider. These 10 questions to ask about insurance coverage can help you get the answers you need.

How can you advocate for yourself if you don't
have adequate coverage?

One of the first things you should do if you find out that your insurance provider doesn’t offer adequate coverage for fertility treatments is look into cost-saving or financing programs your RE’s practice might offer.

Look into how you can lower your out-of-pocket costs.

Set up a meeting with your employer’s benefits coordinator or HR representative to discuss coverage for fertility treatments and request changes to your plan.

Don't be afraid to talk to a specialist

Many REs have financial specialists on staff who can help guide you through the
complicated ins and outs of insurance coverage. They can often tell you what your
potential costs will be for treatment and what your insurance may cover.