Infertility and Insurance Coverage: What I’ve Learned

By Marie D.

One of the most frustrating aspects of battling infertility is the parallel battle many couples must fight with their health insurance carrier about what’s covered for infertility treatment, and what isn’t.

When my fertility journey began in 2017, I wasn’t worried about insurance coverage. Thanks to the hard work of organizations like Resolve New England, insurance plans issued in Massachusetts (where I live) must cover infertility treatment. (We couldn’t even think about growing our family if we paid out of pocket for it—so thanks!)

I was covered by a plan that I purchased directly through a Bay State-based private insurer because my longtime primary care provider wouldn’t accept my employer’s plan. My husband and I started the long process of testing to determine why we couldn’t get pregnant.

By the time all the tests were in and my doctor saw my abysmal Ovarian Assessment Report, I’d changed jobs and enrolled in my new employer’s health insurance plan.

Big mistake.

My employer’s insurance provider insisted that we do two rounds of Intrauterine Insemination (IUI) before moving to in vitro fertilization (IVF). My doctor felt it wouldn’t be successful, but we went ahead. No luck. When it came time to order the meds for my first round of IVF, the pharmacy called and said it would cost nearly $3,000 because I’d already exceeded the lifetime prescription drug benefit for Assisted Reproductive Technology allowed by my employer’s prescription drug plan because I’d done two pointless rounds of IUI as required by that same employer’s health plan.

I was livid. I was heartbroken. And it took quick action to turn things around and continue on our path.

Here’s what I learned to watch for when it comes to infertility coverage and insurance:

Know your state’s laws: I hadn’t seen this helpful explanation of state laws from Resolve New England when I started fertility treatment. (And, thanks to the hard work of advocates, New Hampshire recently joined this list.) If I had seen it, I might have known to ask about whether my employer was self-insured. Most companies don’t volunteer this information during interviews, so be sure to ask the question or find the information on their website.

Know what “self-insured” means: My mistake was thinking any Massachusetts-based employer had to cover all aspects of fertility treatment if their plans were based in the state. Very large or very small organizations often design a health plan in partnership with a large insurance company. This is called being “self-insured”—which means in most states, your plan is exempt from the fertility coverage mandate, even if your insurance card has a big insurance company name on it. My employer’s plan would cover six rounds of IVF, but capped the coverage of the medications necessary for each round. (I wrote a strongly worded letter to HR about that!)

Know your options: My employer offered to lift the cap on drug coverage for one round of IVF. But I suspected my battle with infertility wouldn’t end that quickly. After doing the math, it made more sense for me to go back to buying a plan directly from a Massachusetts-based company in case I needed coverage for multiple rounds. (I didn’t consider my husband’s health insurance, since his employer is based outside of Massachusetts and most out of state plans don’t honor the Massachusetts mandate.) Luckily, I was in an open enrollment period when this happened, so I could quickly ditch my employer’s plan and buy my own. It’s not the best solution, since I lost any subsidy of my health insurance premium, which essentially means I’m losing some compensation for my work. But it’s a sacrifice I’m willing to make to have reasonable copays for the drugs that make infertility treatment possible.

Have someone knowledgeable walk you through your plan: My employer was not great at communicating the limitations of their policy. I’d met with a benefits counselor and they’d said infertility treatment was covered by the plan. (Technically true, but they omitted some key information about the medication cap.) When in doubt, call the insurance company directly and ask someone to explain the benefits to you. If they don’t administer a part of your plan, such as prescription medications, call that insurer too with your questions. Resolve New England members can also get free consultation with an insurance advocate to learn more about the best questions to ask.

Fighting infertility is tough enough. By asking the right questions, you can reduce the number of battles you face in getting insurance to cover it.

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