Getting Insurance Coverage at Work

A major impediment to access to treatment to resolve infertility is insurance coverage.

Health insurance guarantees that an individual will not have to bear the entire burden of his/her health care expenses. But in the case of infertility, the majority of patients bear the responsibility of covering the costs of treatment. No one expects to receive the diagnosis of infertility. Yet more than 7 million Americans are subject to that diagnosis. 

Depending on the cause of the fertility problem and the therapy used to treat the problem, that cost can be considerable and no one expects that their insurance company will deny them coverage for this medical condition. But most do.

Insurance Coverage – The Basics

Your health insurance policy is an agreement between you and your insurance company. To get this coverage, you or your employer pay or share the cost of a fixed premium each year to an insurer (such as Blue Cross and Blue Shield), who then provides the coverage that pays for various medical expenses.

Your policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits or expenses listed in your policy. These are called “covered services.” Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive.

Keep in mind that a medical necessity such as an infertility treatment is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy.

Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.

Insurance policies vary widely and may even differ from employer to employer from the same insurer. It is important to thoroughly review and seek clarification about the provisions of a particular plan, paying specific attention to covered benefits, exclusions and restrictions as they relate to reproductive health services and infertility diagnosis and treatment.

In order to get accurate information, your health plan administrator should provide you with a copy of your plan’s Summary Plan Description (SPD). It outlines your benefits, covered services and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services are included and will require a co-payment, the rules for pre-existing conditions, and the circumstances under which your employer can change or terminate a health benefits plan.

Types of Health Insurance Plans

Most people are covered by group insurance policies, which are designed to keep the cost of premiums lower by spreading the expense risks among all the members in the group. Some people do not have access to a group plan and thus purchase individual insurance policies for themselves and their families. However, it is often difficult and very expensive to purchase individual insurance policies. Therefore, it is best to obtain coverage as part of a group if possible.

Insurance is either public or private.

Public insurance includes governmental programs such as: Medicare for the elderly and disabled, Medicaid for the poor, the Veterans Administration for those who have served in the armed forces and TriCare for current military personnel and their families.

Private insurance falls into one of the following categories:

1. Commercial Insurance Companies such as Aetna, Cigna, United and others;
2. Non-Profit Insurance Companies such as the numerous Blue Cross/Blue Shield plans across the country;
3. Self-Insuring Groups such as employers who pay benefit claims directly rather than using an outside insurance carrier (which might be hired to serve as the benefits manager).

Insurers are applying managed care techniques to promote lower cost, high quality care whenever possible and typically offer plans with varied levels of controls ranging from tighter, in-network provider choices in Health Maintenance Organizations (HMOs) to hybrid approaches called Point of Service (POS) plans, to more costly and greater individual choice options known as Preferred Provider Organizations (PPOs).

The Laws and Mandates

The above distinctions become particularly important when determining whether or not a state insurance law applies to your insurance plan.

ERISA. For example, pursuant to the Federal Employee Retirement Income Security Act (ERISA), self-insuring businesses are not required to comply with state insurance mandates, although they may voluntarily provide these mandated benefits. Therefore, a state law requiring insurance companies to cover infertility cannot apply to companies that “self-insure,” that is, which do not purchase insurance policies but instead pay medical claims themselves. This is because ERISA prevents states from being able to regulate self-insured companies. However, if drafted correctly, a federal law requiring insurance for diagnosis and treatment of infertility could overcome ERISA and could require all, or at least more, employers to provide infertility insurance.

Unlike typical pregnancy-related services guaranteed nationally as basic health plan benefits under the National Pregnancy Discrimination Act, infertility treatment services are not similarly ensured. Coverage, particularly for assisted reproductive technologies, is extremely limited. In the United States, only one in five employers provide infertility treatment benefits to their employees and these policies vary widely in their comprehensiveness, reimbursement limits, and eligibility requirements.

Although no federal law requires insurance coverage for infertility treatment, 19 states have enacted some type of infertility insurance coverage law. Each law is different, but most can be generally described as either a mandate to cover or a mandate to offer. Follow this link for complete list of state laws.

Mandate to Cover: is a law requiring that health insurance companies provide coverage of infertility treatment as a benefit included in every policy (policy premium includes cost of infertility treatment coverage).

Mandate to Offer: is a law requiring that health insurance companies make available for purchase a policy which offers coverage of infertility treatment (but the law does not require employers to pay for the infertility treatment coverage).

What You Can Do

More and more women and men in their most active and productive years are being afflicted by the physical and emotional hardships of a treatable disease that continues to be inappropriately viewed as “elective.” If you are infertile and your employer does not currently provide infertility treatment coverage, make a formal request for them to do so. Get the support of others covered by the plan who are experiencing similar infertility problems. RESOLVE encourages you to become your own best advocate for expanded health benefits. The evidence justifying the cost-benefit of such coverage is considerable.

• Visit the RESOLVE Advocacy Network section of this website to sign up for Action Alerts, and learn more about state and federal legislation.

Ten states have health insurance mandates that require employers to provide coverage for IVF treatments. If you live in Arkansas, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York or Rhode Island, and you need IVF, you might be eligible for coverage. Find out more by reading the details on each of these 10 states and their IVF mandates. Coverage varies widely so only read the state mandate where your employer is headquartered. If you don’t live in one of these states, you do not have a mandate that covers IVF treatments.

There are six other states that have a different kind of mandate and some of those states might cover diagnostic tests so read up on your mandate if you live in California, Louisiana, Montana, Ohio, Texas and West Virginia.

Here is a link to all of the 17 states and their detailed mandates.

If you do NOT live in one of the 10 states listed above or you are a federal employee, active or retired military, veteran, or on Medicare or Medicaid, keep going.

It’s super important that on your quest for seeking fertility insurance coverage you find out if your current health insurance plan is fully-insured or self-insured or you are part of a government/military coverage plan. What does all of this mean and why does it matter? Here’s the break it down:

Fully-Insured is where your employer is getting their coverage from an insurance company and the insurance company dictates what will and will not be covered through a standard benefits plan. The insurance company is taking all the risk of the plan, so it is considered “fully-insured”.

This can present a challenge for those who want to seek coverage from their employer because the employer doesn’t have control of designing the benefits plan. However, insurance companies can offer “IVF Riders” or “Infertility Riders” which are mini-benefits plans just for IVF or infertility. An employer can add this to their standard benefits plan and offer coverage.

Again, the design of the “rider” is done by the insurance company so your employer may not have much say in how many cycles are covered, coverage for medications, etc. But it’s worth asking your Human Resources or Benefits Administrator to request a quote for an “IVF Rider” to see what the insurance company can provide. This Rider would be available to all employees, not just you. Advocating for fertility insurance coverage will go a long way in convincing your HR or benefits administrator that a Rider is worth it!

Self-Insured, which is usually the case for large companies, is where the employer is the decision-maker and they have a big say in dictating what is covered and what is not. In self-insured plans, the employer is taking on all the risk of the plan, which is where the term “self-insured” comes from. One downside to self-insured employers is they are outside of any state mandates. Even if you are in a mandated state, if your employer is self-insured, they do not have to follow the mandate law in that state.

This process is a bit different.If you're a Federal Employee, Active-Duty Service Member, Military Retiree, a Veteran, or covered by Medicaid or Medicare, your insurance is provided by the Federal Government. Here is breakdown of coverage for IVF medical treatments:

Federal Employee: Starting in 2024 and as summarized in the 2024 Federal Benefits Open Season Highlights, linked below, coverage is now required for artificial insemination procedures and medications, as well as the drugs for three cycles of IVF annually.

2024 Federal Benefits Open Season (See overview of Fertility Benefits on page 7)

In addition, there are 24 health plan options that provide broader services, including IVF, as listed in Appendix A, but the benefits vary and not all plans are accessible to everyone.

However, it is our understanding that the following Blue Cross Blue Shield (BCBS) plan is available to all federal employees and covers IVF services and medications:

https://www.fepblue.org/our-plans/-/media/PDFs/Brochures/Standard-and-Basic-Option-brochure-2024.pdf

Please see pages 14 and 16 of the BCBS plan and the additional pages referenced, and as always, read the coverage details carefully before enrolling in any plan.

These changes are a result of federal employees advocating for more comprehensive fertility coverage, so it’s important to maintain pressure on OPM and your HR contacts until all FEHB plans include comprehensive family building benefits. RESOLVE is here to help you advocate. Please email coverageatwork@resolve.org with your name, city, state, and the federal department or agency where you work so we can stay in touch with you.

Infertility Discrimination: Did you know that infertility discrimination is covered by the Americans with Disabilities Act? Just like pregnancy is protected, so too is infertility discrimination. In 1998, the U.S. Supreme Court stated that reproduction is a “major life activity” and conditions that interfere with reproduction should be regarded as disabilities per the American Disabilities Act.

Based on recent settlements, the Equal Employment Opportunity Commission (EEOC) reinforces the rights of individuals undergoing fertility treatments to have their employers provide reasonable accommodations, including excused absences. Learn more about infertility discrimination at EEOC’s Enforcement Guidance on Pregnancy Discrimination and Related Issues (Section I (A)(3)(c). To file a complaint regarding infertility discrimination, visit https://www.eeoc.gov/employees/charge.cfm.

Active Duty Service Member or Military Retiree: If you are covered by TRICARE, it specifically excludes coverage for IVF. Read more here.

Veterans: If you are receiving your healthcare through the Veterans Health Administration, they had been banned from offering IVF, but Congress is allowing the VA to offer IVF for FY 2017 to wounded Veterans.  Since this is a brand-new benefit as of October 1, 2016, we do not yet know exactly how wounded Veterans will access this benefit, but contact us at info@resolve.org if you believe you qualify and we will help you navigate the process.  Read more about how RESOLVE and its partners advocated for this change in Congress.

Medicare or Medicaid recipient: If you receive your health insurance from Medicare or Medicaid, neither offers infertility or IVF coverage. This is a complicated process to change these policies. If you are covered by Medicare or Medicaid and need IVF, we’d love to hear from you as we advocate to change these policies. Email RESOLVE at info@resolve.org.

Self-Employed or Individual Plan: You are paying for your own health insurance! In most cases, you are getting your health insurance through one of the state or federal exchanges. At this time, most of the exchange plans are mirroring the mandate coverage if you are in one of the eight mandated states listed above.

Otherwise, most plans are not covering IVF. At this time, RESOLVE is not advocating for IVF coverage in all the state exchange plans. We simply do not have the resources to take on this task. If you are frustrated by the lack of IVF coverage offered in individual plans, we’d like to hear from you. Email us at info@resolve.org.

If you are just not sure on what type of insurance plan you have, this is a question your HR department can easily answer for you. Ask them, then come back to this page. We’ll be right here waiting…

Navigating benefits as a union member can be difficult, but there are multiple ways for you to begin the process of requesting new or expanded family-building benefits.

RESOLVE is here with a few tips successfully used by union members to secure better benefits.

You don’t need to be a collective bargaining expert to figure out where to start

The process of collective bargaining for benefits for members of your union is undoubtedly daunting. But you don’t need to be an expert to start the process and make the ask.

RESOLVE recommends consulting your Union’s benefits booklet first. Take a look at the benefits structure and familiarize yourself with the union’s trust before considering bargaining. Putting in the request to your union’s trust could allow you to skip the collective bargaining process altogether. The trust typically makes these decisions and can directly request that family building benefits be added to the plan for you and your fellow union members.

There is strength in numbers

While many Coverage at Work advocates are individuals who ask their employers for benefits, we know that unions are based on strong organizing. Involving other members of your union in making the ask can strengthen the argument and show decision-makers just how many of their members are being impacted.

RESOLVE is here to help, so contact us if you would like to organize a group call to discuss what strategy might work best for your organization and how to present the best-united front. We’ll work with you to create a template request from your group as a whole and support you every step of the way!

Even if you make the ask yourself, you’re not alone

If you feel a single request will suffice in getting the ball rolling, we are all for that, too. You still don’t have to go through this process alone. RESOLVE staff and volunteers with specific union experience are here to help you create a plan of action, submit your request, and navigate the unique structure of your union.

Ready to get started?

Making this ask is all about strategy and it will be different for everyone. Whether you are ready to submit a request on your own or you want to make the ask with your fellow union members, we’re ready to help.

Schedule a time for an initial call to get started and plan your strategy with RESOLVE by emailing CoverageAtWork@resolve.org.

“It was emotionally difficult to share my story and advocate for infertility coverage at work while undergoing treatment. But succeeding in gaining treatment for so many people has made me feel incredibly empowered, and has actually given me a second wind to continue treatment. I feel like my employer values my health and thinks this disease is worth treating. While advocating for infertility coverage at work I also interacted with several people who shared their own personal stories of infertility. There are more of us than I realized.”

“If it were not for guidance from the RESOLVE website about what information and statistics to provide an employer I don’t know that the benefits that will be available next year would have ever existed. Once a year I have emailed the same director of benefits to let me know I am still patiently waiting as are others for fertility coverage. And here we are, finally real change right before my eyes. Thank you God and Thank you RESOLVE.”

"RESOLVE empowered and prepared me to formally approach my employer and request infertility treatment benefits. Infertility coverage was offered for the first time the following year."

"Don't be afraid to ask your HR about fertility coverage. Now more than ever employees have the power in getting what they want from their employer. There are multiple paths a company can take to offer a solution for fertility coverage. As an employee, you can absolutely present them to HR yourself. Most companies only started to offer fertility benefits because an employee asked for it." 

“I am a planner and when it comes to infertility it is difficult to plan ahead (as we know) however Resolve’s Coverage at Work Tool Kit truly empowered me to take action and plan ahead. I wasn’t sure what treatments I would need on my infertility journey however I wanted to be prepared and have the option for all treatment being covered by insurance including IVF especially as it was a treatment my husband and I could not afford.  Using the tool kit allowed me to advocate for infertility insurance coverage through my employer that included IVF. I know have IVF covered through my employer and I am extremely grateful for my employer offering this benefit to all employees. I will begin IVF soon and am eager to have my miracle baby.”

More Coverage at Work Success Stories

There’s no one-size-fits-all solution for individuals dealing with infertility just like there’s no one-size-fits-all way to obtain coverage through your employer. Here are additional employee resources for requesting fertility insurance cited by RESOLVE’s Coverage at Work toolkit. Use this information to ask your workplace for fertility insurance benefits.

Additional Resources:

• Mercer 2021 Fertility Benefits Study
• Employee Fertility Benefits: An Evidence-Based Guide – UPDATED 9.24.21
• Family Equality Council: LGBTQ Family Building Survey
• FertilityIQ: The FertilityIQ Family Builder Workplace Index: 2019 – 2020
• Glassdoor: 4 in 5 Employees Want Benefits or Perks More Than a Pay Raise; Glassdoor Employment Confidence Survey
• Willis Towers Watson: Employers prioritize family-friendly benefits: Findings from the 2020 Emerging Trends in Health Care Survey – US