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Current Status of Insurance for Fertility Services

As you are well aware, one of the most important aspects of infertility treatment is insurance coverage for fertility services. We would like to direct your attention to three areas which you may find useful as you consult with patients with a chief complaint of infertility.

As many as 20% of patients will have coverage for infertility services, which is designated as diagnostic only. This means that only testing will be covered but not treatment. In these patients, it is very important to do all testing first before any treatment is started, such as ovulation induction with clomiphene citrate. After treatment has started, no further testing will be covered.  With diagnostic only coverage, the patient is considered self pay for all infertility treatment.

Illinois is one of 15 states which have state mandated coverage for infertility services. If a patient has state mandated coverage, she must first meet the definition of infertility which is one year of unprotected intercourse in a women age 35. 

Although Illinois has this designation, if patient is employed by a company with main headquarters located outside of Illinois or if the company is privately owned or has less than 25 employees, they do not have to offer infertility coverage. 

With the Affordable Care Act (ACA), infertility mandates are likely to be offered until the end of 2015, but states will begin decisions about the mandates this year. Additionally under the ACA, the provider, hospital and pharmacy networks are being narrowed by the plans. For example, if a drug prescribed is not on the exchange plan formulary, it may cost more for the patient.

The Family Act of 2013 is a bill in the U.S. Senate and U.S. House of Representatives that provides a tax credit for the out of pocket expenses related to IVF procedures, medications, and fertility preservation. It provides approximately $12,000 in a tax credit for eligible tax payers, and the credit may carry forward for five years. 

In order for a bill to become law, we urge you to write your U.S. Senators and U.S. Representative asking them to co-sponsor The Family Act – if you click here you will be directed to the online form, or go directly to RESOLVE to learn of different ways to support this important legislation and RESOLVE’s efforts.