Fertility Treatments and the American Affordable Care Act

Why the Upcoming American Affordable Care Act is lacking when it comes to fertility treatments;

When President Obama signed the Affordable Care Act into law back in March 2010, for the one in eight infertile couples in the United States, the law held the hope of finally having access to comprehensive insurance for costly fertility treatments. However, upon closer look, it seems that nothing much will change for those people who need to use fertility treatments to have a family.

Historically, individual insurance coverage in the United States for fertility treatments has been very sparse. Most insurance plans don’t cover the procedures, or only cover part of the cost. In some cases insurers will only cover a fertility consultation and not the treatment itself.

Employer sponsored health plans aren’t much better. According to a study from Resolve: The National Infertility Association, only 20 percent of businesses offer their employees coverage for fertility treatments. The main reason for this, they said, is cost. Which may not be such an unreasonable argument, as a single IVF cycle can cost thousands of dollars and success is never a guarantee..

Affordable Care ActFertility Treatment vs. Essential Benefits

So if the biggest hurdles to overcome are insurance coverage and the cost of treatment, will the ACA (Affordable Care Act) help these couples? Well it depends.

It’s likely that overall the ACA will improve access to health insurance for many poor and sick Americans. But when it comes to fertility treatments, specific coverage guarantees are not spelled out in the law.

What the law does, instead of issuing a specific list of mandated medical services, is that it outlines ten categories of “essential health benefits”. What they are, are ten categories of medical services that must be covered with every new health insurance plan sold next year.

In rules issued by the federal government last year, rather than the government mandating a list of minimum services for each essential benefit category, the individual states would determine which medical services get coverage as essential benefits.

The procedure was for each state to submit a so called “benchmark plan” to the federal government. These “benchmark plans” are just health insurance plans that were sold in the state during 2012. But these plans will become the model for all future health insurance plans sold in the states under the Affordable Care Act starting in 2014. What this basically means is that whatever medical services are included in the “benchmark plan” will become the “essential benefits” under the Affordable Care Act for that state.

Where does fertility treatment come in?

With fertility treatment not specifically spelled out as an essential benefit, it was left up to each state to determine on its own if it was or was not an essential benefit.

According to the Obama administration, the reason for this move was so that the local transition to the new healthcare law would cause as little disruption as possible. But the bigger effect of this is that now there will be vast disparities in health plans nationwide, with some states potentially offering fertility coverage and others not.

The benchmark plans for the majority of states have already been submitted and approved. So far only 15 are requiring coverage for fertility treatments. Check the status of your state here.

Looking ahead

Even though the Affordable Care Act does a lot to try to improve the American health care system, it still has a long way to go. The way forward is also likely to be tough, especially considering the government’s July decision to delay implementing the employer mandate until 2015. The mandate was originally set to take effect on Jan. 1, 2014 and would have required businesses with 50 or more full time employees to provide their workers with health insurance. So basically what this means is that larger businesses have more time to determine what health insurance plans they will offer to their employees and whether or not fertility will be part of those benefits.

As bigger issues like the implementation of the state health insurance marketplaces and insurance tax credits take center stage, it is likely that fertility treatments and their place in ‘essential benefits’ will take a back seat, and we have no way of knowing how long that will last.

Of course, there’s always the hope that Congress will act to fix the essential benefits disparities, but with intractable legislative gridlock now a common feature in Washington, don’t expect action anytime soon.

Michael Cahill is Editor of the Vista Health Solutions blog. He has a degree in Journalism from SUNY New Paltz and previously worked as a reporter for the Poughkeepsie Journal and an editor for the Rockland County Times. Follow him on Twitter at  @VistaHealth and @ElectronicMike

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