Infertility, defined as not being able to get pregnant after trying for one year, is a difficult situation for individuals and couples to experience. According to Reproductive Biological Endocrinology, approximately 48.5 million couples experience infertility. For these couples, becoming pregnant with the help of an infertility doctor is not always possible as fertility treatments are expensive and typically not covered by insurance.
Few states require private insurance plans to cover infertility services and just one state requires coverage under Medicaid. These common difficulties pose the question of whether insurance should include fertility coverage. In Colorado, a recently passed bill requires insurance companies to cover infertility services.
State Laws And Infertility Coverage
In the U.S. just 17 states have mandated infertility insurance coverage, including Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. However, it is important to keep in mind that while infertility coverage is mandated, it is not necessarily free. Policyholders may still be responsible for co-pays.
In addition, coverage is only available to individuals who have proven that they have met the criteria for infertility. This typically involves getting a doctor’s note that shows that conception has not occurred after trying for 12 months if the patient is under 35, six months if over 35, or if the patient has been unable to carry a pregnancy resulting in a live birth after a year. Certain states require individuals to have experienced infertility for up to five years.
The Colorado Legislature recently passed a bill that requires private health insurance companies to cover the diagnosis and treatment of infertility, as well as fertility preservation services. Fertility coverage requirements outlined in the “Colorado Building Families Act” are considered the most comprehensive coverage for infertility in the Mountain West.
Before this act, the state of Colorado only required insurance companies to cover certain fertility treatments, such as artificial insemination and diagnostic lab tests. The Colorado Building Families Act (CBFA) expands this coverage to include in vitro fertilization (IVF), which has a much higher success rate. The CBFA also includes coverage for the sperm and egg freezing process for individuals with medical conditions, such as cancer, that may threaten their reproductive systems.
Why Was It Not Covered In The Past?
Despite a need for fertility care in the U.S., these services remain widely inaccessible to many couples due to cost. Until recently, fertility services were not covered by private or public insurers in states like Colorado. This is because most insurance companies do not see fertility treatments as “medically necessary.” When coverage is available, some types of fertility services, such as fertility testing, are more likely to be covered than others, such as IVF.
The average cycle of IVF costs between $12,000 and $17,000, according to the University of Iowa Stead Family Children’s Hospital. These exorbitant costs have resulted in ongoing debates about whether insurance companies should cover IVF and other fertility treatments. However, apprehension remains as some studies have shown that pregnancies resulting from assisted reproductive technology (ART) are more likely to be high-risk compared to spontaneously conceived pregnancies.
What Infertility Coverage Includes
The CBFA was signed into law on April 1, 2020 with the goal of providing greater access to fertility diagnosis, treatment, and preservation for Coloradans.
This bill includes coverage for modern fertility techniques, including a minimum of three rounds of in vitro fertilization if recommended by the covered member’s physician. Previously, Colorado only required insurance companies to cover certain fertility treatments, such as diagnostic lab testing and artificial insemination. With the new act, coverage is expanded to cover IVF which has a much higher success rate.
All individual and group health insurance benefit plans issued or renewed in Colorado must conform to this new mandate to provide coverage for the diagnosis and treatment of infertility, as well as the delivery of standard fertility preservation services. The law currently does not mandate any cap and only requires health plans to cover three completed oocyte retrievals, meaning some insurance companies may impose a three procedure cap.
Under the CBFA, plans must provide these three completed oocyte retrievals with unlimited embryo transfers. Single embryo transfers may be used when recommended and when deemed medically appropriate. Health plans may not impose any limitations, exclusions, or other restrictions on the coverage of fertility medications that differ from the limitations, exclusions, or restrictions that are imposed with other prescription medications covered under the benefit plan.
Cost Of Infertility Options
The cost of fertility treatments, whether out-of-pocket or partially covered by insurance, can range significantly depending on factors like location, insurance company, and type of service. Fertility treatments like egg freezing are now covered by many insurers but not all. According to Northwell Health fertility expert Christine Mullin, MD, OB-GYN, the average out-of-pocket cost for egg freezing is between $9,500 and $17,000.
Fertility treatments like intrauterine insemination (IUI) are available to women who do not have a male partner but want to become pregnant with donor sperm, couples who want to achieve pregnancy using their partner’s sperm but are having trouble conceiving due to erectile dysfunction or low sperm count, or same-sex couples using donor sperm. IUI is typically covered by insurance but those without adequate health coverage can expect to pay an average of $1,000 to $1,600 per cycle.
IVF can be costly without insurance with just one round costing an average of $13,000 to $23,000. According to Mullin, it takes between two to three IVF cycles to achieve a successful pregnancy. With the new mandate in Colorado, more individuals and couples can get the fertility treatments they seek with little to no out-of-pocket costs.
How Colorado’s Infertility Coverage Is Opening Doors
The 2020 passage of the CBFA has opened doors for many other states to follow suit. The historic legislation made Colorado the eighteenth state with an infertility insurance law and the twelfth state to offer IVF coverage. Colorado is also the tenth state to offer fertility preservation to individuals with medical conditions that could cause iatrogenic infertility, such as cancer.
This new mandate will allow countless individuals and couples the opportunity to start or grow their families without financial barriers. The bill also affects employers who have more than 100 employees. Companies that offer health insurance plans as part of a comprehensive employee benefits plan can expect fertility coverage to work in much the same way as coverage for prescription drugs, preventive services, and other health care.
Fertility coverage in Colorado includes requirements similar to other insurance mandates, such as the Maryland Mandate Infertility Insurance law that went into effect on January 1, 2021. Before the mandate, insurance did not provide unwed women with IVF coverage. New revisions to the mandate have removed the marriage requirements for patients seeking treatment, as well as reduced the two-year “waiting” period to just one year of unprotected sexual intercourse.
Other states, such as New York, New Jersey, and Rhode Island have recently started providing infertility coverage to citizens who meet certain qualifications.
Get More Information from New City Insurance
Interested in learning more about the Colorado fertility mandate and how it may impact your business? Request a consultation with the experienced benefits consultants at New City Insurance.