The new mandate, which officially went into effect on January 1, 2020, requires that all large insurance plans (those serving 100 employees or more) offer coverage for up to three cycles of in-vitro fertilization (IVF). With an average cost per cycle of around $23,000, this mandate should go a long way toward relieving the financial burden of infertility medicine for the millions of people who require it. The mandate also requires that all insurance plans cover egg and sperm freezing for medically necessary purposes, such as if one partner will be undergoing chemotherapy. Other examples of medical necessity include sex reassignment surgery, sickle cell anemia, bone marrow transplants, and surgery for endometriosis.
When it comes to IVF, New York may be leading the way in terms of this new coverage requirement. However, it’s important to note that there are several limitations. The mandate, unfortunately, does not cover IVF or sperm freezing for same-sex, male couples. Also ineligible are those on Medicaid, those at small and medium-sized businesses whose insurance plans apply to less than 100 employees, those with individual insurance plans, and those with plans through companies that self-insure.
It is estimated that half of New Yorkers with health insurance qualify for the mandated IVF coverage based on the eligibility requirements noted above, though there must be a diagnosis or determination of infertility first.
According to the state of New York, infertility is defined as a disease or condition where clinical pregnancy is unable to be achieved after 12 months of regular, unprotected sexual intercourse. For women who are 35 and older, the diagnosis is applied after six months of regular, unprotected sexual intercourse. Infertility can be diagnosed in either the male or female partner.
Cost is a major consideration when determining the next steps of infertility treatment. And while the New York Infertility Mandate certainly takes coverage a step further for millions of individuals, it’s still important to understand the basic benefits of your plan.
Many insurance plans do offer some degree of infertility coverage. This may be limited to a certain number of cycles, or a lifetime cap on total treatment costs. At New Hope Fertility Center, we work closely with our patients to determine what insurance companies cover IVF and what the benefits of their individual plans are. Keep in mind that if you are self-insured your plan is governed by federal—not state—law, so the mandate does not apply.