Insurance Coverage of Infertility Treatments Statement
Infertility is a disease or condition that results in the abnormal functioning of the male or female reproductive system interfering with the ability to achieve a pregnancy or of a woman to carry a pregnancy to live birth. The duration of the failure to conceive should be 12 or more months before an investigation is undertaken, unless medical history, physical findings or age dictate earlier evaluation and treatment. Infertility affects 6.1 million people in the United States. This figure represents 1 in 10 couples in which the woman is of reproductive age. This very significant number demonstrates that infertility affects a large percentage of our population. Couples in their most active and productive years are distracted by the physical and emotional hardships of the disease. Infertility is a crisis of the body, a crisis of the mind and a crisis of the spirit and calls into question a person’s view of themselves, their life goals, their faith, their relationship with their spouse and with others. Infertility impacts a couple’s general health, their marriage, job performance and social interactions it brings a deep sense of grief and loss. Infertility also exacts an enormous toll on society. The social norm in the United States is one that heavily encourages, if not expects, married couples to bear and raise children, and questions the values of couples that do not.
Health insurance guarantees that an individual will not have to bear the entire burden of his/her health care expenses. But in the case of infertility, the cost of treatment for the majority of those touched by the disease, is borne exclusively by the patient. Depending on the cause of the fertility problem, and the therapy used to treat the problem, that cost can be considerable. Some of the less invasive therapies such as hormone therapy can range from $200-$3,000 per cycle. Tubal surgery can range from $10,000-$15,000, requires a hospital stay and poses a high risk of complications. Assisted reproductive technologies (ART) can range from $10,000-$18,000, per cycle, but in many infertility cases is the most effective means of treatment.
No one expects to receive the diagnosis of infertility. Yet more than 6 million Americans will. No one expects that their insurance company will deny them coverage for this medical condition. But most do. A major impediment to access to treatment to resolve infertility is insurance coverage. Currently those with access to treatment are a small subset of infertility sufferers: a fraction of the population residing in one of the fifteen states that have passed laws requiring some level of infertility coverage (each states has enacted quite different requirements), those who work for the small number of employers who voluntarily provide such a benefit, or those who have access to resources that will enable them to finance the treatment out of pocket, predominately couples who are Caucasian and upper middle class.
Infertility treatment is an important aspect of reproductive health care, yet only 1/4 of all health plan sponsors with at least 10 employees provide some level of coverage for infertility treatment. Offering a comprehensive infertility treatment benefit with appropriate utilization controls may actually reduce costs and improve outcomes by eliminating the inappropriate use of costly covered procedures and allowing specialists to use the most effective, efficient treatment for a specific type of infertility. The cost of including a well managed infertility benefit is minimal. Massachusetts, the state with the most comprehensive mandate for infertility coverage, found that the cost of coverage was one of the lowest among its mandated benefits at $2.49 per member per year.
A 2002 study published in the New England Journal of Medicine found that the percentage of high-order pregnancies was greater in states that did not mandate insurance coverage for IVF. The authors of the study noted that mandatory coverage is likely to yield better health outcomes for women and their infants since high-order births are associated with higher-risk pregnancies. These pregnancies have a higher frequency of complications and higher rate of preterm delivery, the cost of which can exceed $340,000 (triplet delivery). States with mandates are likely to realize a significant decrease in multiple gestation pregnancies and significant cost savings due to fewer high risk pregnancies and fewer premature babies.
RESOLVE’s Position on Insurance Coverage of Infertility Treatments
Public policymakers, employers and insurers have been slow to recognize infertility as a disease. The time to change this is now. RESOLVE believes that couples should not have to spend their life savings, second mortgage their home, or incur thousands of dollars of debt to treat a disease and to fulfill a fundamental aspect of life the desire to bear children and raise a family. RESOLVE endorses state and federal legislation that will require insurers to cover the costs of appropriate medical treatment. RESOLVE believes the option to pursue medical treatment for infertility must be available to all those who need treatment, not solely those with the resources to pay for the treatment out of pocket. Decisions made during infertility treatments must be strictly medical decisions, not financial ones removing the financial barriers to treatment will result in safer outcomes for women and their offspring.
While fifteen states have recognized the importance that health insurance include a comprehensive infertility benefit, many of those suffering from the disease of infertility who reside in those states still do not have access to the coverage. A federal law, the Employee Retirement Income and Security Act (ERISA), exempts self-insured health plans, those maintained by the majority of employers, from state insurance regulation. Well financed lobby organizations representing the insurance industry and large employers successfully argued at the time of ERISA’s enactment, and continue to do so today, that it is administratively burdensome and expensive for companies with operations in various different states to abide by 50 different state insurance laws. Also exempt from state insurance mandates is the Federal Employee Health Benefits Program (FEHBP) – the largest employer-sponsored health insurance program in the nation, covering nearly nine million federal employees, retirees and their dependents. FEHBP is administered by the Office of Personnel Management and is governed by the United States Code. Lobby organizations representing employers with self-insured health plans have been able to successfully preserve ERISA pre-emption and advocate for flexibility in the design of their benefits package while patients who need treatment continue to be denied access to that care. Therefore, RESOLVE works for the enactment of a federal law that would amend ERISA and the United States Code to require insurance coverage across the board for all group health plans.
RESOLVE: The National Infertility Association, is a national non-profit organization whose mission since 1974 has been to provide timely, compassionate support and information to those touched by infertility. RESOLVE works to increase public awareness of the issues surrounding infertility and the various family building options available to those working to resolve their infertility. RESOLVE’s strength lies in its more than 50 volunteer led chapters which provide education and support to the local communities in virtually every state.