If you’re set on trying to have a family, but your health care plan doesn’t offer IVF coverage, what can you do? Your homework. There are a few options for accessing insurance, but it’s not an easy process. The additional work may seem overwhelming when you’re already feeling discouraged and drained, but the effort could make all the difference on your conception journey.
It was worth it for me. I struggled with female- and male-factor infertility and recurrent miscarriages for more than a decade. I learned how to access IVF benefits not offered by my employer. My efforts resulted in two IVF babies out of ten pregnancies. I was able to overcome feelings of helplessness by taking some control over my benefits and ability to pay for what I felt was so critical to my life—having a family.
Professionally, I focused my attentions on conducting research with legislators, employers, and insurers to learn what they needed to know to support IVF benefits. All of the desired information is available in a resource I created, the Policymaker’s Guide to Fertility Health Benefits.
My advice is to consider all of your options and start with the one that connects with your strengths and comfort level.
Here are five key ways to secure IVF coverage.
1. Ask Your Employer for Benefits
This may seem like a bold move if your company doesn’t already offer them. However, some employers take the advice of the insurance brokers they work with and don’t always realize that they can ask brokers to add coverage for fertility treatment. They can ask their broker to:
- Search for an IVF rider benefit to add to their existing plan.
- Provide two health plans to their employees. One that offers IVF benefits and one that doesn’t.
- Replace a current plan with one providing IVF benefits.
Employers need to hear from their employees. Why?
- You are how the employer learns there is a need for IVF coverage.
- The more employees who contact their Human Resource Departments, the better employers understand there should be no limitation to the scope of coverage provided.
- Employers want to be competitive so they want to know which companies are offering coverage and what benefit packages they offer.
- Employers are either self-insured (insurance companies manage benefits, but the employer pays the claims) or fully insured (insurance companies manage benefits and pay the claims). Self-insured employers are motivated to offer IVF coverage once they learn the cost savings associated with providing benefits.
With reasonable infertility benefits, patients tend to transfer fewer embryos in an IVF cycle. The estimated healthcare cost associated with a singleton pregnancy (through birth) is $21,458 while twins is $104,831 and triplets is $407,199. There is also savings in mental health benefits. When employers are informed that this could apply to 1 in 6 employees, they consider it more seriously.
2. Ask Your Insurer for Coverage
When requesting coverage, your personal story will make your request for additional benefits (called an Exemption of Benefits or Predetermination of Coverage) memorable. With a letter from your doctor and additional research, you should try to convince the insurance company that you are a good investment with a good chance of success (you have greater than a 5% chance of live birth), have a medical need (IVF is your only option), and can save them money (patients with IVF benefits have more singleton births). These reasons will help justify creating a win-win solution for everyone.
You can remind the insurer that IVF benefits provide access to affordable health care, which enables patients to make treatment decisions based on medical recommendations, rather than financial concerns.
Many people believe that the insurance coverage they’re offered is finite. But, you can request special consideration.
The goal is to make the insurance medical director’s job easy to override the company’s policy and provide you with benefits. You can remind the insurer that IVF benefits provide access to affordable health care, which enables patients to make treatment decisions based on medical recommendations, rather than financial concerns.
You can share research showing that without insurance benefits, patients tend to transfer multiple embryos, which will increase the chances of high-risk pregnancies and premature babies. There are quotes from insurance company medical directors who draw a direct line between insurers offering IVF benefits and significant savings on the maternity and neonatal side. These facts are a Google search away or within The Policymaker’s Guide to Fertility Health Benefits.
3. Purchase Non-Group Insurance
I purchased non-group insurance to have my IVF cycles covered. I found a non-group plan (or individual plan not offered through an employer) that provided IVF benefits. These plans have a hefty monthly premium; however, it is significantly less than paying out-of-pocket for a full IVF cycle.
Many people believe that the insurance coverage they’re offered is finite. But, you can request special consideration.These plans exist. States either have designated organizations and/or an insurance department to help consumers navigate through the available insurance plans to determine which one will work best. To find your state resources you can do a search for “organization to find a health insurance plan (name of state)” and/or “(name of state) insurance department.” The nonprofit that I run, Fertility Within Reach, also has a direct link to list the insurance department of each state. Typically, you can apply for these plans if there has been a change in your life (employment, family, etc.) or during a yearly open enrollment period.
4. Participate in Clinical Research Trials
Applying for a fertility clinic research spot is another option for paying for treatment. Fertility centers often seek patients for clinical trials. The treatments and discounts offered by clinics can vary. You can search online or visit specific websites such as centerwatch.com or clinicaltrials.gov to find trials by condition and location. Once you have located a research trial that interests you, you have to apply.
If you’re selected to participate, read the fine print of the agreement. You want to make sure you clearly understand what your responsibilities are and what the clinic is offering before signing. Those participating receive a significant benefit while helping advance health care.
5. Seek Employment from a Company That Provides Infertility Coverage
Some people assume they will be guaranteed insurance coverage if they live in a state with an infertility mandate. While there are states with laws requiring fully insured employers to provide IVF coverage, self-insured employers can decide not to offer this benefit. What matters is the state where the employer’s headquarters is located and which companies provided insurance benefits.
For example, let’s say you live in Arizona, a state without mandated benefits, and work for CVS. CVS has headquarters in a state with a law requiring IVF benefits, which means you will have benefits even though you live in Arizona. The good news is that many types of businesses offer benefits, from retail (TJ Maxx), banking (Bank of America), to technology (Apple). In theory, everyone should be able to find a job where they can apply their skill set in a company offering benefits.
Not all companies offer the same breadth of benefits. One company may voluntarily provide $15,000 in coverage to use toward IVF while others may contribute $4,000 or up to six IVF cycles. Often you can collect substantial information on which benefits different employers offer by participating in online forums and surveying your personal community. Forums can be found on Facebook or other online communities.
If you aren’t able to find a full-time job with IVF coverage, you can consider a part-time job where it is offered. Pregnantish has featured the story of Christian Borrero-Colon, a US serviceman who took a job with Starbucks specifically to obtain infertility insurance coverage.
Keep in mind that seeking or adding employment with an employer providing IVF benefits does not need to be a lifelong change.
Despite the many challenges of infertility, feeling informed and empowered helps you navigate the winding road with a little less stress. If these options don’t appeal or don’t work for you, that’s OK. Many people apply for a grant or finance their treatment. There is no judgment on any path you take. You know what works best for your life and will bring you closer to your goal of building a family.
Oona Tempest/Kaiser Health News
After years of trying to have a baby without success, Brenna Kaminski and her husband, Joshua Pritt, decided to try in vitro fertilization.
Only 15 states require insurance to cover fertility treatments, and Florida, where Kaminski and Pritt live, isn't one of them. Still, the couple's insurance, from Pritt's job at an energy company, did — putting them among the fortunate minority of Americans whose insurance plan covers the pricey fertility procedure. Kaminski and Pritt gamed out what their share of the cost would be for one round of IVF: $2,700, the out-of-pocket maximum under their policy.
Instead, after many twists and turns with two specialty practices, they paid more than $15,000 for two rounds of IVF, including all medicines. And, as is true for the majority of the procedures nationally (success rates vary from 12% to 49% depending on a patient's age), neither round resulted in a viable pregnancy. "This whole thing has been a nightmare," said Kaminski, 37, who does freelance marketing and writing. "The stress has been unbelievable."
About 1 in 5 women have trouble getting pregnant, and IVF has become a common path to parenthood for many. But even as demand grows, insurance coverage remains limited. About 27% of companies with 500 or more employees covered IVF in 2020, up from about 24% in 2015, according to Mercer, a consulting firm.
"Infertility is a disease and should be treated as such, and insurance coverage should reflect that," said Dr. Kara Goldman, associate professor of obstetrics and gynecology at Northwestern University. "Coverage is often incomplete because people too often don't see infertility as equal to other diseases."
Kaminski's insurer, Blue Cross and Blue Shield of Illinois, offered a list of in-network IVF providers near the couple's home in Melbourne, Fla. For in-network care, the couple would be responsible for 20% of the costs. For out-of-network care, they would have to pay 40%.
The first in-network specialists they tried, in spring 2020, had an office nearby, in Viera, Fla. But after seeing the doctor, they learned they had to travel 3½ hours to Miami, where the physician performed the IVF procedures over three separate visits.
This story was produced in partnership with Kaiser Health News.
The couple paid about $2,700 out-of-pocket for the medicines alone. They also paid an additional $500 because the fertility clinic required them to use an out-of-network lab for blood tests.
In November 2020, the couple decided to try again, with another fertility medical group listed in their Blue Cross provider network. It was in Winter Park, Fla., about an hour's drive from their home.
Kaminski visited with doctors at the Center for Reproductive Medicine, and they scheduled her to begin the procedure at their facility in the same building. But that facility, the Orlando Avenue Surgery Center, was not in the Blue Cross network.
Kaminski said the surgery center told her that it was likely to be added to the Blue Cross network soon, and she appealed to the insurer for a waiver to have the center's care considered in-network. She was told by customer service agents for the insurer that she'd get the waiver, but she didn't get that confirmed in writing. Still, she went through with the procedure.
It took place in 2021, and Kaminski again expected to pay about $2,700 out-of-pocket for the care from the IVF specialist in Winter Park. She knew she would face separate out-of-pocket costs for the medications used in IVF.
But because her care was deemed out of network by Blue Cross, Kaminski said, she was billed more than $6,000 by the clinic and its surgery center. That was in addition to nearly $4,000 in out-of-pocket drug costs.
Kaminski has spent nearly a year trying to get Blue Cross to treat her second round of IVF as in-network. She said it's unfair for Blue Cross to have listed the Winter Park fertility clinic in its provider network if its doctors performed the actual IVF procedure in an out-of-network surgery center. The surgery center is owned by some of the clinic's doctors.
In a statement to KHN, the Center for Reproductive Medicine's executive director, Stephen Brown, wouldn't address Kaminski's case specifically even though she had given permission for him to discuss it. In an email, Brown wrote that the clinic was transparent with all its patients that its surgery center was not in Blue Cross' network.
Brown said low reimbursement rates aren't what has kept the surgery center out of the Blue Cross network. Instead, he said, the insurer didn't act quickly, taking more than four years to add the surgery center to its provider network. "The reason for not initially being in network with BCBS was based solely on the lack of response from BCBS," Brown said.
Before any treatment is done, Brown said, the clinic gives its patients estimates of the costs of their procedures based on their insurance. Kaminski received an estimate that said she could expect to pay $3,000 to $4,000 just for the transfer of the embryos grown in the lab into her uterus.
In March 2021 — about a month after Kaminski completed her treatment — the Winter Park surgery center was added to Blue Cross' provider network.
In February 2022, KHN reached out to the provider and insurer. Within two weeks, Blue Cross told the couple it would consider all the services they received at the surgery center in-network, and it paid all its bills in full. Kaminski and Pritt no longer owed anything to the center. Blue Cross had initially said it would pay a nominal portion of disputed bills that totaled $21,450 for care in 2020 and 2021 because the surgery center was out of network.
Blue Cross also confirmed to the couple that in January 2021 it had granted them a waiver so all the surgery center's bills could be considered in-network. Mistakenly, the waiver hadn't been applied, so they faced the high out-of-network charges.
"It's finally making logical sense," Pritt said after learning that their billing dispute was resolved. "It's good to know we won't be getting any more bills."
After Blue Cross decided to cover the IVF in Winter Park, the couple received $1,600 back from Orlando Avenue Surgery Center.
John Simley, a spokesperson for Blue Cross and Blue Shield of Illinois, said: "With non-routine waivers, mistakes can happen. The good news is they generally get fixed quickly."
In this case, though, it took nearly a year.
Experts say Kaminski's case shows that even when people have coverage for IVF, they can be left with huge bills. Also, insurers' lists of in-network providers are not always accurate. "It feels like a bait-and-switch," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
A new federal insurance law, the No Surprises Act, went into effect in January 2022. It says patients don't have to pay more than the in-network cost sharing amount if the insurer's provider directory gave inaccurate information.
Whether the law would apply in cases such as Kaminski and Pritt's is unclear. Even if it did, the law took effect too late for them.
Betsy Campbell, chief engagement officer at Resolve: The National Infertility Association, a patient advocacy organization, said Kaminski's case shows that insurance coverage isn't always designed around the patient. "Infertility treatment is a series of very complex procedures involving lab work, surgery, anesthesia, and it needs to be provided in a way that the insurance system has not always respected," she said.
Too often, insurance makes a couple jump through hoops to get the care they need, Campbell said. "Everyone should have the right to build a family, and it should not matter what employer you work for, or what state you live in, or how big a check you can write," Campbell said.
Kaminski and Pritt aren't giving up on having children. For now, they're pursuing other fertility treatments that aren't IVF.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).
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