It’s true: Infertility treatments are often excluded from insurance coverage

According to a new report from the World Health Organization, about 17.5% of the adult population worldwide, or 1 in 6, experience infertility.

The numbers, according to an April 23 WHO press release about the report, underline the need to improve access to affordable, high-quality fertility care.

In Wisconsin, the political debate is over whether coverage for such treatments should be mandated in health insurance plans.

“During #NationalInfertilityAwarenessWeek, I’m drawing attention to a reproductive health disparity that doesn’t always get the attention it deserves: Infertility is treated differently from other diseases and conditions and is often excluded from insurance coverage,” Senator Kelda Roys said April 26 in a Twitter after.

The post included an image with the following words: “Raising is a reproductive right. The cost of treatment currently deters many people from starting a family.”

Is Roys right that infertility is often excluded from insurance coverage?

Let’s see.

Insurance coverage

When asked to back up the statement, Roys pointed out that infertility is much more common than people realize.

“As common as it is, many insurers don’t cover infertility treatments. Instead, patients have to pay out of pocket for what can be very costly treatments,” Roys said in an email to PolitiFact Wisconsin. “For example, in vitro fertilization, a common treatment for infertility, can cost thousands of dollars per cycle, and many people need multiple cycles to achieve a viable pregnancy. Insurance coverage varies from state to state, and about 75% of health insurance policies do that infertility treatments don’t cover.”

Roys pointed to an article in the Journal of Health Economics, which stated that only 25% of health plans cover infertility treatment nationwide, and that coverage varies significantly by state.

That article dates from 2007 and is therefore outdated. However, another research article she cited, published in December 2011 by Duke University Press, also stated that “only 25% of health insurance policies in the United States cover infertility treatments.”

That may have changed in the intervening decade, but there are other indications that Roys is right.

First, only 20 states, including neighboring Illinois, require some level of infertility coverage from insurance companies in their state. That means the majority — including Wisconsin — has no such requirement.

According to RESOLVE, the National Infertility Association, the 20 states that require private insurers to cover some form of fertility coverage are Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New York, Ohio, Rhode Island, Texas, Utah, and West Virginia.

“As of June 2022, 20 states have passed fertility insurance laws, 14 of those laws include IVF (in vitro fertilization) coverage, and 12 states have fertility preservation laws for iatrogenic (medically induced) infertility,” RESOLVE said.

Sarah Smith, director of public affairs for the Wisconsin Office of the Commissioner of Insurance, confirmed that the Badger State “does not mandate coverage for infertility services.”

In its $104 billion budget proposal for 2023-25, Wisconsin Gov. Tony Evers called for requiring state health insurance and self-insured health plans to cover infertility diagnosis and treatment and fertility preservation.

However, the proposal was one of the more than 540 measures cut from the budget by Republicans who control the legislature. The GOP is still working on its budget plan.

Infertility in numbers

According to the U.S. Department of Health and Human Services, approximately 9% of men and 11% of women of childbearing age in the United States have fertility problems.

According to the U.S. Centers for Disease Control and Prevention, about 1 in 5 (19%) of married women ages 15 to 49 with no previous births are unable to conceive (infertility) after a year of trying. Also, about 1 in 4 (26%) women in this group have difficulty getting pregnant or maintaining a pregnancy.

According to a September 15, 2020 report from the Kaiser Family Foundation, the out-of-pocket cost of fertility treatments can be in excess of $10,000, depending on the services received. “This means that in the absence of insurance coverage, fertility care is out of reach for many people.”

Also, the Guttmacher Institute, a research and policy organization focused on sexual health and reproductive rights, estimated that the cost of successful treatment ranges from about $1,000 to $40,000, depending on the services needed. Those services may include fertility assessments and counseling, hormone treatments, surgery, sperm and egg donation, in vitro fertilization and other assisted reproductive technologies.

Sabrina Corlette, research professor, founder and co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy, also said that infertility treatments are often excluded from major medical insurance coverage.

“Unless a state makes it mandatory, or in the case of an employer self-funded plan, unless the employer decides it wants to cover it,” Corlette said in an email to PolitiFact Wisconsin.

The lack of coverage was one of the reasons Wisconsin received a C rating on RESOLVE’s State Fertility Scorecard, which tracks how “fertility-friendly” each state is. Factors in the assessment include the availability of doctors and specialists, support groups in the state, and the number of women who have difficulty conceiving or giving birth.

Illinois got an A-, as did Connecticut and New York. Massachusetts, New Jersey and Maryland scored A’s.

Aside from Wisconsin, 12 states had a C class, including neighboring Michigan.

Our verdict

Roys said “infertility is treated differently from other diseases and conditions, and is often excluded from insurance coverage.”

Several states, including neighboring Illinois, require some degree of infertility coverage from insurance companies in their state, but Wisconsin currently has no coverage requirements. And academic research articles have reported that “only 25% of health insurance plans in the United States cover infertility treatments.”

For a statement that is correct and nothing important is missing, our rating is True.

It’s true: Infertility treatments are often excluded from insurance coverage

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