The Affordable Care Act and How It Affects Infertility Patients

More than 7 million Americans who struggle with infertility must now face the complication of understanding the impact of the Affordable Care Act (“ACA”) and how it affects coverage options for this multifaceted illness. In addition to the medical and emotional hurdles patients must cope with, there is the question of how to pay for quality treatments that offer real promise of achieving family building goals. One of the most challenging issues is insurance coverage for fertility treatment. The state insurance mandates vary from state to state, and insurance coverage varies among carriers and the plans they offer. Employment status, and whether your employer offers insurance that covers fertility treatments, are also considerations. The ACA may offer new alternatives for those who are dealing with infertility. We believe the following some useful information will give you some clarity and direction.

Healthcare Reform and Pre-Existing Conditions

The Health Insurance Marketplace, commonly known as Health Exchanges, opened on October 1. Created under the ACA, Health Exchanges are intended to provide access to affordable individual health insurance policies for Americans and legal residents, particularly those not covered by employer group coverage. The ACA also provides for subsidies to help lower-income individuals offset premium costs. Under the ACA, you can no longer be rejected by an insurer for pre-existing conditions. Starting in 2014, insurers cannot exclude you from an insurance policy due to a diagnosis of infertility, whether your state does or does not require infertility coverage. Insurers also cannot charge you more for a policy sold on the Health Exchange because of a pre-existing condition. (Some grandfathered individual insurance plans can still decline or surcharge coverage for pre-existing conditions, but now you can choose another plan on your state exchange.) The ACA mandates four types of plans, Bronze, Silver, Gold and Platinum, with varying premiums and deductibles. To help consumers make “apples to apples” comparison of available insurance products, insurance sold on Health Exchanges must provide coverage for a minimum of the same set of “essential health benefits.” These include outpatient care, hospitalization, emergency services, prescription drugs, maternity and newborn care, preventive and wellness services and pediatric services. Insurers can also provide additional health benefits if the plan chooses.

Infertility Coverage vs. Availability

The ACA does not mandate infertility treatment coverage. According to Sean Tipton, Director of Public Affairs for the American Society for Reproductive Medicine (ASRM), “The ACA is completely silent on infertility.” And while states can require their insurance companies to cover infertility treatments, according to ASRM only 15 (Massachusetts, Maryland, Connecticut, Rhode Island, Arkansas, California, Hawaii, Illinois, Louisiana, Montana, New Jersey, New York, Ohio, Texas and West Virginia) require at least some infertility insurance coverage. Barbara Collura, President and CEO of RESOLVE: The National Infertility Association, has stated that such states can either add infertility coverage as an essential health benefit in plans sold on their Exchanges, or they can drop their mandate. Massachusetts and Maryland have decided to make infertility treatment an essential health benefit in plans sold on their exchanges. It appears that the insurance plans in Connecticut and Rhode Island are also requiring some coverage of infertility treatment. Other mandated states’ positions have not yet been clarified. States that did not mandate coverage for fertility treatment before the ACA are not expected to require infertility coverage in plans sold on their health exchanges. How can you find out if your state has opted to include coverage of fertility treatment as an essential health benefit in plans on its health exchange? Visit www.healthcare.gov, and go to your state’s health insurance exchange to see the available plan benefits. For some states (such as Texas, New Jersey and Arkansas, which have not created state exchanges, or New York, which has), you may have to fill out the online enrollment form to access to plan details. Filling out the enrollment form does not commit you to purchase any insurance product. While insurance purchased on the health exchange will provide coverage for essential obstetrical and neo-natal services, many people will still have to pay for fertility treatment out of pocket.