Infertility Coverage – “Essential” Health Benefit?

Health InsuranceThe Debate Marches On: Should Infertility Coverage Be Considered an “Essential” Health Benefit?

In a perfect world, the tens of thousands of women suffering from infertility who consult reproductive specialists every year would know that their medical treatment would be covered by their health insurance. Infertility is, after all, considered a disease – or in vitro fertilization centers would not be held to some of the medical profession’s most rigorous reporting requirements by the Center for Disease Control.

Yet the list of minimum “Essential Health Benefits” established by the U.S. Department of Health and Human Services under the Affordable Care Act lists only these 10 broad benefit categories: (1) “ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.

It may be telling that “oral and vision care” is singled out under pediatric services, and infertility care is not mentioned in the same breath as maternity and newborn care. Though it’s not surprising, since only 15 states consider Reproductive Assistance Technology (ART) “essential” enough to mandate coverage. And when coverage is provided, it is often severely limited.

A Question of Cost

When the first “test tube” baby was born in 1978, so was a new medical specialty. The science of infertility is complex and expensive, and therein lies the largest objection. Unlike diseases that require treatment in order to maintain quality of life, or life itself, some argue that ART is not a medical necessity; no one “needs” to have a child in order to live. So why should medical insurance take on the higher risks of ART:

  • An average pregnancy in the U.S. costs $17,500 – ART-related pregnancy expenses add 30% to the pregnancy medical COSTS.
  • On average, each cycle of IVF costs $8,158, plus an average of $4,000 for medications. Typically, multiple cycles are required.
  • To increase the chance of success, multiple embryos are often implanted. As a result, recent studies have shown that assisted reproductive technologies have contributed to an increase in the number of multiple births – dangerous for mothers and babies alike.
  • Statistics confirm that IVF pregnancies are high-risk compared to normal pregnancies. But actual maternity costs are insignificant when compared to newborn medical costs in instances where the infants have medical conditions.

The actual numbers are significant:

  • 10% of U.S. women of child-bearing age has consulted a doctor for infertility issues.
  • Since 7% of women trying to have a baby fail to conceive after 12 months of unprotected intercourse, the popularity of IVF is increasing. In 1996, there were 64,681 IVF procedures reported to the CDC. In 2008, there were 148,055 – an increase of 230%.
  • In 2004, 8.1% of all newborns were low birth weight (less than 5.5 pounds), the highest percentage since the early 1970s.
  • Preterm births cost society an estimated $26 billion per year.
  • In 2008, more than 61,000 babies were born in the U.S. as a result of assisted reproduction procedures.

The truth is, insurance companies – like all companies – need to be profitable in order to survive. They have a responsibility to their shareholders. Those profits are determined by the difference between what they collect in premiums and what they pay out in claims – taking into account sales, marketing, underwriting and administrative costs. Traditional insurance companies cannot sustain the loss ratios inherent in a high-risk market such as the infertility market. They were never meant to.

So it’s really no surprise that, outside of mandated states and a few group plans, traditional medical insurers have decidedly avoided offering infertility coverage. They will continue to do so. And if they are mandated by the Government to assume the high risks, millions of Americans will help bear the cost, as they do today for the uninsured. People who do have infertility insurance, as well as rank-and-file American taxpayers, are already paying for IVF pregnancies and IVF babies for both U.S. citizens and non-citizens who come to the U.S. for IVF procedures.

The infertility community itself needs to shoulder a share of the responsibility for the lack of traditional insurance coverage. By carving out Infertility as a medical specialty, with the high costs that come along with it, they have created a niche that can only be serviced by specialty insurance providers.

Fortunately, there are a variety of alternatives.

A Specialized Market Requires Specialized Solutions

Potential parents need not be left out in the cold if mandates for infertility insurance are not forthcoming.

  • Search assisted reproduction insurance in your search engine; there are solutions to help you.
  • Insurers can offer Assisted Reproduction Insurance products as a coverage extension via endorsement to group plans
  • Group policies can continue to provide existing maternity and newborn care coverage by offering a “carve out” option for IVF diagnosis and treatment and high-risk pregnancies and newborn costs
  • Insurers can avoid individual member coverage by referring coverage to a high-risk insurance market
  • Infertility insurance can be offered through a supplemental insurance program filling the gap of traditional insurance coverage

What IS Essential, is a Solution

 Ask a childless couple with the dream of building a family if treatment for infertility is “essential.” Ask a couple with a happy, healthy family if their children are “essential” to their life. Global IVF is fighting tirelessly to create awareness – and action – that will give men and women struggling with infertility the insurance coverage that will make their dream an affordable reality. The final reality may be that traditional insurance coverage – and even the promises of the Affordable Care Act – may not offer an answer.

But the good news is that there are viable solutions already in place in the marketplace, ready to provide hope and happiness. And that is essential.

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