When someone is faced with infertility or has barriers to building a family, often added to the emotional and physical burdens is a financial burden of paying for the out of pocket costs for medical treatments.
Even if you have health insurance coverage, not all benefit plans are created equal. Actually, they are various forms of insurance coverage plans depending on what your employer has chosen for their employee benefits plans. So how do you know what type of plan you have? Where to start? And most importantly, what are your options if you need coverage? RESOLVE is here to help make this fact finding process easy for you, in 3 steps.
Step 1: Do you live in a state with an IVF mandate?
Ten states have health insurance mandates that require employers to provide coverage for IVF treatments. If you live in Arkansas, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York or Rhode Island, and you need IVF, you might be eligible for coverage. Find out more by reading the details on each of these 10 states and their IVF mandates. Coverage varies widely so only read the state mandate where your employer is headquartered. If you don’t live in one of these states, you do not have a mandate that covers IVF treatments. There are six other states that have a different kind of mandate and some of those states might cover diagnostic tests so read up on your mandate if you live in California, Louisiana, Montana, Ohio, Texas and West Virginia.
If you do NOT live in one of the 10 states listed above or you are a federal employee, active or retired military, veteran, or on Medicare or Medicaid, keep going.
Step 2: Who is paying for your insurance?
It’s super important that on your quest for seeking coverage you find out if your current health insurance plan is fully-insured or self-insured or you are part of a government/military coverage plan. What does all of this mean and why does it matter? Here’s the break it down:
Fully-insured is where your employer is getting their coverage from an insurance company and the insurance company dictates what will and will not be covered through a standard benefits plan. The insurance company is taking all the risk of the plan, so it is considered “fully-insured”. This can present a challenge for those who want to seek coverage from their employer because the employer doesn’t have control of designing the benefits plan. However, insurance companies can offer “IVF Riders” or “Infertility Riders” which are mini-benefits plans just for IVF or infertility. An employer can add this to their standard benefits plan and offer coverage. Again, the design of the “rider” is done by the insurance company so your employer may not have much say in how many cycles are covered, coverage for medications, etc. But it’s worth asking your Human Resources or Benefits Administrator to request a quote for an “IVF Rider” to see what the insurance company can provide. This Rider would be available to all employees, not just you. Advocating for coverage will go a long way in convincing your HR or benefits administrator that a Rider is worth it!
Self-insured, which is usually the case for large companies, is where the employer is the decision maker and they have a big say in dictating what is covered and what is not. In self-insured plans, the employer is taking on all the risk of the plan, which is where the term “self-insured” comes from. One downside to self-insured employers is they are outside of any state mandates. Even if you are in a mandated state, if your employer is self-insured, they do not have to follow the mandate law in that state.
Government or Military Employees
This process is a bit different. If you are a Federal Employee, Active Duty Service Member, Military Retiree, a Veteran, or covered by Medicaid or Medicare your insurance is provided by the Federal Government. Here is breakdown of coverage for IVF medical treatments:
Federal Employee: As of November 2016 RESOLVE has learned that in plan year 2017, no federal health plans will offer coverage of assisted reproductive technology (ART) procedures or services related to such procedures. The Office of Personnel Management (OPM) has not required that plans offer infertility coverage or even offer IVF coverage. But we can learn from other causes and make a difference. Case in point: for the 2017 plan year, OPM has mandated that all of the insurance plans offered to federal employees fully cover autism treatment. When OPM made this announcement in the spring of 2016, they specifically stated that federal employees advocated for this change and OPM listened. If you are a federal employee, you should reach out to your HR department and OPM and let them know you want IVF coverage included in your health plan options, and please encourage others to do the same (resources are provided in Step 3 below). The more people who complain about the lack of coverage, the more likely change will occur, although this will take time. RESOLVE will also be reaching out directly to leaders in the Office of Personnel Management. Please email firstname.lastname@example.org with your name, city, state, and the federal department or agency where you work so we may keep in touch with you.
Infertility Discrimination: Did you know that infertility discrimination is covered by the Americans with Disabilities Act? Just like pregnancy is protected, so too is infertility discrimination. In 1998, the U.S. Supreme Court stated that reproduction is a “major life activity” and conditions that interfere with reproduction should be regarded as disabilities per the American Disabilities Act. Based on recent settlements, the Equal Employment Opportunity Commission (EEOC) reinforces the rights of individuals undergoing fertility treatments to have their employers provide reasonable accommodations, including excused absences. Learn more about infertility discrimination at EEOC’s Enforcement Guidance on Pregnancy Discrimination and Related Issues (Section I (A)(3)(c). To file a complaint regarding infertility discrimination, visit https://www.eeoc.gov/employees/charge.cfm.
Active Duty Service Member or Military Retiree: If you are covered by TRICARE, it specifically excludes coverage for IVF. Read more here.
Veterans: If you are receiving your healthcare through the Veterans Health Administration, they had been banned from offering IVF, but Congress is allowing the VA to offer IVF for FY 2017 to wounded Veterans. Since this is a brand-new benefit as of October 1, 2016, we do not yet know exactly how wounded Veterans will access this benefit, but contact us at email@example.com if you believe you qualify and we will help you navigate the process. Read more about how RESOLVE and its partners advocated for this change in Congress.
Medicare or Medicaid recipient: If you receive your health insurance from Medicare or Medicaid, neither offers infertility or IVF coverage. This is a complicated process to change these policies. If you are covered by Medicare or Medicaid and need IVF, we’d love to hear from you as we advocate to change these policies. Email RESOLVE at firstname.lastname@example.org.
Self-Employed or Individual Plan: You are paying for your own health insurance! In most cases, you are getting your health insurance through one of the state or federal exchanges. At this time, most of the exchange plans are mirroring the mandate coverage if you are in one of the eight mandated states listed above. Otherwise, most plans are not covering IVF. At this time, RESOLVE is not advocating for IVF coverage in all the state exchange plans. We simply do not have the resources to take on this task. If you are frustrated by the lack of IVF coverage offered in individual plans, we’d like to hear from you. Email us at info@ resolve.org.
If you are just not sure on what type of insurance plan you have, this is a question your HR department can easily answer for you. Ask them, then come back to this page. We’ll be right here waiting…
Step 3: Make the Ask for Coverage
Below is the final step in determining what options you have for seeking coverage through your employer. No matter which type of insurance you have, no employer big or small will make any change if the employee does not ask for it. Your voice as an employee is a powerful tool and it starts with clicking on the image below to lead you on your quest for coverage!