Figuring out whether you're insured for IVF is not for the faint of heart.
Not everyone thinks that IVF should be covered by health insurance. That is a nuanced debate I will leave to a future newsletter. But the fact remains that some jurisdictions do decide to cover it and others decide not to. It turns out that coverage is pretty nuanced as well.
Recently, I was asked by the New York Times to help create an infographic showing state-by-state insurance coverage of IVF in the US. My first thought was: why would this be interesting? Then I dug in.
Most states simply don't require infertility services to be covered. Among those that do, some explicitly exclude IVF. Others limit it — to one round in Hawaii, for instance, or two rounds in Connecticut. Some cover all the bells and whistles — sperm injection, preimplantation testing, freezing — some none. Some states mandate that an insurer has to give an employer the option of offering infertility coverage, but don't require them to actually provide it.
Some states require that you be married to your co-procreator. Some only allow you to use your own gametes. Most don’t include embryo transfer to a surrogate.
Some states give a pass to religious organizations. All states are subject to a federal law that exempts self-insuring businesses from state mandates.
It took me, plus a heroic fact checker and a crackerjack editor, many hours to nail down what was actually covered where, for whom, and under what circumstances. We poured over summaries by the American Society for Reproductive Medicine, Resolve, and the National Conference of State Legislatures, we read laws and their addenda, we talked to state insurance bodies and lawyers who'd worked on laws, and, in one case, emailed a local fertility doctor to ask "What the....?"
All this to say, if journalists trained to figure these things out found it a taxing exercise, imagine how ordinary people must feel. My heart goes out.
This is the point in any story on US medical insurance where I usually get to say: Look north, my American friends! Canada has this single payer thing all figured out! We don't give a thought to our insurer when we get our vaccines or c-sections or hip replacements!
Alas, where infertility coverage is concerned, Canada cannot gloat. Just as US coverage varies greatly by state, in Canada it varies greatly by province. Most provinces offer no IVF coverage. Last I checked, Manitoba offered a tax credit. The province of Quebec, between 2010 and 2015, had an extensive program covering IVF, but it was shut down due to expense and poor design. Just as Quebec's program wound down, Ontario's started up — completely different, but no less complicated and fraught. Canada is no model.
Below, I highlight just a few of the interesting details I discovered while working on this. I wish I could provide a link to the full infographic, but there doesn't appear to be one, though there is an interesting Q&A with the editors about the special section it appeared in. If you have access to the print New York Times from this past Sunday, November 10, make sure to check out the entire special insert, called "Your Fertility Now."
Only 9 US states specifically require some coverage of IVF.
In many states, couples with unexplained infertility become eligible after one year of regular sex without conceiving — as is currently recommended by doctors — but in New Jersey and Arkansas, they have to wait two years, and in Hawaii and Texas five years.
Illinois mandates coverage of four completed egg retrievals, and if you have a live birth, then two more.
In Delaware, up to six egg retrievals are insured for women under age 45. But embryos can be transferred up to age 50.
In Delaware, only one embryo can be transferred at a time. In Connecticut, no more than two.
Rhode Island has a minimum age for IVF: 25.
Maryland specifically allows for same-sex females to be covered for IVF if they have tried and failed with six rounds of artificial insemination.
Ohio issued a bulletin to clarify that its mandate to cover "infertility" services did not include IVF, because it is "not essential for the protection of an individual's health."
Both New Hampshire and New York will be introducing new and comprehensive requirements in January, 2020.
New Hampshire's new law will give the state's insurance commissioner the right to impose penalties on insurers who don't base coverage on up-to-date information.
New York's new law will prohibit discrimination based on expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, age, sex, sexual orientation, marital status or gender identity.
In 2016, the latest year for which statistics are available, 76,892 infants were born in the US as a result of IVF, ranging from 9,885 in California to only 74 in Alaska.
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