Alina Salganicoff Follow @a_salganicoff on Twitter Ann. Many states provide exemptions for small employers (<50 employees) or religious employers. Despite this recommendation, in aforementioned states with mandated fertility preservation coverage for iatrogenic infertility, it remains unclear if this benefit extends to transgender individuals, whose gender affirming care can result in infertility. Figure 7: Women Seeking Help to Become Pregnant Tend to Be Age 35+, White, Higher Income, and Privately Insured. For example, if someone has abnormal thyroid hormone levels, thyroid medications may help the patient achieve pregnancy. Veterans Affairs (VA): Infertility services are covered by the VA medical benefits package, if infertility resulted from a service-connected condition. Fifteen states have laws in effect requiring certain health plans to cover at least some infertility treatments (a “mandate to cover”) (Figure 4). Obviously, those on Medicare who would use this benefit are those who receive Medicare due to being disabled 2+ years, as those going on Medicare at age 65 would not be expected to become fertile. If a patient has large fibroids distorting the uterine cavity, surgical removal of these benign tumors may allow for future pregnancy. The CDC finds that use of IVF has steadily increased since its first successful birth in 1981. Stigma around infertility, intensive and sometimes long or painful treatment regimens, and uncertainty about success can take a toll. 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. While some private insurance plans cover diagnostic services, there is very little coverage for treatment services such as IUI and IVF, which are more expensive. Treatment to correct physical causes of infertility are also covered. 3. On a federal level, efforts to pass legislation to require insurers to cover fertility services are largely stalled. This applies to Medicaid members, ages 21 through 44, who are experiencing infertility. A higher share of Black and Hispanic women are either covered by Medicaid or uninsured than White women and more women with private insurance sought fertility help than those with Medicaid or the uninsured. Some grants and other financing options also stipulate funds must go towards a married couple, excluding single and unmarried individuals. Other plans cover both. According to the Medicare Benefit policy manual, “reasonable and necessary services associated with treatment for infertility are covered under Medicare.” However, specific covered services are not listed, and the definition of “reasonable and necessary” are not defined. This brief examines how access to fertility services, both diagnostic and treatment, varies across the U.S., based on state regulations, insurance type, income level and patient demographics. Others place restrictions based on marital status; for example, until May 2020, IVF benefits were only available to married women in MD. Medicaid coverage in Oregon covers many medical services. Imaging (e.g., pelvic ultrasound, hysterosalpingogram (. States have the option to cover pregnant women under CHIP. Additionally, it is not always made clear if LGBTQ individuals meet eligibility criteria for these benefits, without a diagnosis of infertility. Many people require fertility assistance to have children. Large employers are more likely than smaller employers to include fertility benefits in their employer-sponsored health plans. Tests usually include a physical exam, semen analysis, blood tests, and special procedures. Some states require private insurers to cover infertility services, the most recent of which was NH in 2020. Medicare does not have a National Coverage Determination (NCD) which specifically addresses infertility services. An estimated 10% of women report that they or their partners have ever received medical help to become pregnant. Since then, ASRM has provided updated guidance on what conditions should be met and measures should be taken before safely resuming fertility care. This includes infertility counseling, blood tests, genetic counseling, semen analysis, ultrasound imaging, surgery, medications and IVF (as of 2017). A study of nearly 400 women undergoing fertility care in Northern California demonstrates this overall trend, with the lowest out of pocket spending on treatment with medication only and the highest costs for IVF services (Figure 3). In a committee opinion, ASRM concluded it is the ethical duty of fertility programs to treat gay and lesbian couples and transgender persons, equally to heterosexual married couples. Opens in a new window. 4. If your doctor recommends IVF to freeze eggs prior to treatment, log in and complete the infertility registration form. Employers may also decline to cover this benefit if the diagnosis and treatment of infertility conflicts with the organization’s religious or moral beliefs. Many fertility treatments are not considered “medically necessary” by insurance companies, so they are not typically covered by private insurance plans or Medicaid programs. About 25% of the time, infertility is caused by more than one factor, and in about 10% of cases infertility is unexplained. For those who need it, this includes access to fertility services. 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. However, these changes are being challenged in the courts because they conflict with a recent Supreme Court decision stating that federal civil rights law prohibits discrimination based on sexual orientation and gender identity. However, the cost of egg or sperm retrieval and subsequent cryopreservation can be prohibitive, particularly if in the absence of insurance coverage. As the bill was introduced, it was estimated to result in a net annual increase of $2,197,000 in premium costs or 0.0015% for enrollees in plans subject to the mandate. https://www.kff.org/.../coverage-and-use-of-fertility-services-in-the-u-s Iatrogenic, or medically induced, infertility refers to when a person becomes infertile due to a medical procedure done to treat another problem, most often chemotherapy or radiation for cancer. Figure 6: One State Medicaid Program Covers Infertility Treatment and Eight Cover Some Diagnostics. Provision of any infertility treatment was uncommon (16% of clinics), likely requiring referrals to specialists who may not accept Medicaid or uninsured patients.10 The majority of patients who rely on publicly funded clinics are low-income and would not likely be able to afford infertility services and treatments once diagnosed. Among states that do not have a mandate to cover, nine states5 and DC have a benchmark plan that includes coverage for at least some infertility services (diagnosis and/or treatment) for most individual and small group plans sold in that state.6 Two states (CA and TX7) require group health plans to offer at least one policy with infertility coverage (a “mandate to offer”), but employers are not required to choose these plans. In others, patients are eligible after 1 year. Utilization of fertility services has dropped drastically during the COVID-19 public health emergency. Fifteen states require some private insurers to cover some fertility treatment, but significant gaps in coverage remain. This includes men and women with infertility, many LGBTQ individuals, and single individuals who desire to raise children. Insurance coverage of fertility services varies by the state in which the person lives and, for people with employer-sponsored insurance, the size of their employer. NOTES: This is not an exhaustive list of infertility services. Misconceptions and stereotypes about fertility have often portrayed Black women as not requiring fertility assistance. NSFG data show that significantly fewer women with Medicaid have ever used medical services to help become pregnant compared to women with private insurance. Some specific exceptions exist, such as electroejaculation (EEJ), which is covered by Medicare. • Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time. No state Medicaid program currently covers artificial insemination (IUI), IVF, or cryopreservation (Appendix 2). However, it is unclear how accessible these services are in practice, and provision of infertility treatment is not mentioned. Without the explicit protections that have been dropped in the current rules, LGBTQ patients may be denied health care, including fertility care, under religious freedom laws and proposed changes to the ACA. In a 2013-2014 study of 1615 publicly funded clinics, a high share reported offering preconception care (94% for women and 69% for men), but fewer offered any basic infertility services (66% for women and 45% for men). For example, if a semen analysis reveals poor sperm motility or the fallopian tubes are blocked, the sperm will not be able to fertilize the egg, and intrauterine insemination (IUI) or in-vitro fertilization (IVF) may be necessary.