One of the most common questions we receive is:
"Does my Marketplace health insurance plan cover infertility treatment or IVF?"
Unfortunately, the answer is not always straightforward.
Coverage for infertility testing, fertility treatment, and in vitro fertilization (IVF) varies significantly depending on where you live, the insurance carrier, your specific plan, and state insurance laws.
Does the ACA Require IVF Coverage?
No.
While the Affordable Care Act (ACA) requires Marketplace plans to cover ten Essential Health Benefits, infertility treatment and IVF are not federally required benefits. This means health plans are generally not required to cover IVF unless a state has adopted its own fertility coverage requirements.
As a result, coverage varies dramatically from one state to another.
What Fertility Services May Be Covered?
Even when IVF is not covered, many ACA plans may provide benefits for:
Infertility diagnosis and testing
Office visits with fertility specialists
Hormone testing
Blood work and laboratory services
Ultrasounds and diagnostic imaging
Treatment of underlying medical conditions that contribute to infertility
Certain fertility medications
Coverage for these services is typically subject to the plan's deductible, copays, coinsurance, and network requirements.
Understanding the Difference Between Infertility Coverage and IVF Coverage
Many consumers assume that because a plan covers infertility services, it automatically covers IVF.
That is not always the case.
A plan may:
Cover infertility testing only
Cover diagnosis and treatment but not IVF
Cover fertility medications but not embryo transfer procedures
Cover fertility preservation but not infertility treatment
Cover IVF only under certain circumstances
This is why reviewing the Summary of Benefits and the Evidence of Coverage is so important.
States With More Comprehensive Fertility Coverage
Several states have adopted laws requiring certain health plans to provide infertility benefits, including IVF coverage in some cases.
Examples include:
Colorado
Connecticut
Delaware
Maryland
Maine
New Hampshire
New Jersey
New York
Rhode Island
Utah
Washington, D.C.
However, eligibility requirements, cycle limits, and plan types vary by state. Some mandates apply only to fully insured plans and may not apply to self-funded employer plans.
States With Limited Fertility Mandates
Some states require only limited fertility-related benefits.
For example:
Coverage for infertility diagnosis
Coverage for fertility preservation before cancer treatment
Coverage for medically necessary fertility preservation due to treatment-related infertility
These laws do not necessarily require IVF coverage.
Georgia, for example, recently expanded protections related to fertility preservation for individuals undergoing treatments that may impact fertility, but Marketplace IVF coverage remains limited.
Questions to Ask Before Choosing a Plan
If fertility treatment is important to you, consider asking:
Does the plan cover infertility testing?
Does the plan cover fertility medications?
Are reproductive endocrinologists in-network?
Is IVF covered?
Are there lifetime limits on fertility benefits?
Does the deductible apply?
Are prior authorizations required?
The answers can vary significantly, even between plans offered by the same carrier.
The Bottom Line
When it comes to infertility treatment and IVF, not all health insurance plans are created equal.
Many ACA Marketplace plans will help cover the diagnostic side of infertility care, but IVF coverage is still largely determined by state law and individual plan design.
Before enrolling, it is important to review both the Summary of Benefits and the detailed plan documents to understand exactly what fertility services are covered and what costs may apply.
At Willis Advisory & Insurance, we help individuals and families review their health insurance options and understand how benefits such as infertility treatment, fertility preservation, and IVF may be covered based on their state and plan selection.
Because when it comes to growing your family, understanding your coverage can make all the difference.