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The Affordable Care Act and Infertility

Update: January 31, 2012

On December 16, 2011 the Department of Health and Human Services (HHS) issued a Bulletin regarding the Essential Health Benefits plan. This Bulletin stated that HHS will give states more flexibility in determining the Essential Health Benefits in their state.    HHS requested public comment on the Bulletin through January 31, 2012.  RESOLVE signed-on to letters from a coalition of organizations responding to this Bulletin.  The Bulletin does not outline what is in the Essential Health Benefits and clearly states that HHS will not be determining that – the states will.   Based on this Bulletin, there could in fact be 50 different “Essential Health Benefits Plans” – one for each state.

What is RESOLVE doing?

RESOLVE has been following the creation of the Essential Health Benefits Plan since the passage of the Affordable Care Act in 2010. Follow RESOLVE and its Blog as we provide updates on this process over the course of next 6-12 months. Want to get involved?  Learn more here.

In November 2011, RESOLVE sent a letter to HHS along with over 5,000 signatures from people across the U.S. demanding that the Essential Health Benefits Plan include coverage for infertility.  Read RESOLVE’s letter to HHS here.

What is the Affordable Care Act?  

(Content provided by www.healthcareandyou.org)

The Affordable Care Act is a health care law that aims to improve our current health care system by increasing access to health coverage for Americans and introducing new protections for people who have health insurance. (Read more here.) 

How does cost or the lack of insurance coverage impact access to infertility medical care?

For many years a few states have had comprehensive insurance mandates for the diagnosis and treatment of infertility. Besides the obvious, that thousands of babies have been born as a result of these insurance mandates, we have learned about other advantages to having coverage and how it impacts the care and treatment of infertility:

  • When cost is not an obstacle, the BEST treatment for that patient can be offered first. When a patient is paying out-of-pocket for their care, they often times try lower cost treatments, such as medication or IUI’s, in the hopes of becoming pregnant. Yet they may have received a clear diagnosis for their infertility that cannot be overcome by these types of treatments. Money and valuable time is wasted. With coverage, they can receive the best care at the right time based on their diagnosis.
  • When cost is not an obstacle, patients can make better decisions about their care. With IVF, this may mean choosing to transfer just one or two embryos during an IVF procedure. This leads to lower multiple births and healthier outcomes for mom and baby. IVF is a course of treatment, and typically patients find they must undergo two or three cycles for the greatest chance of success. However, if the patient can only afford one or two cycles, they may pressure their clinic to transfer more embryos – hedging their bets so to speak – in the hopes of a greater likelihood of a pregnancy. This can lead to serious health outcomes such as multiple births, prematurity, and putting the mother at risk.
  • Medical decisions should not be made on how much cash a patient has at that moment. With infertility, time is a critical factor in the diagnosis and treatment of the disease.  Patients don’t have the luxury of waiting a few years to save up the money to pursue a medical treatment that they need.

If the Essential Health Benefits includes infertility, will that mean my employer’s plan will automatically add it? And does this mean that every insurance plan will now be required to include infertility coverage?

All new health insurance plans sold to individuals and small businesses, and plans purchased in the new Affordable Insurance Exchanges, must include the Essential Health Benefits beginning in January 2014.   In other words, insurance plans must cover the Essential Health Benefits in order to be certified and offered in the Exchanges. The Essential Health Benefits do not apply to grandfathered plans, large group, or self-insured plans.   So depending upon where you get your coverage and the type of plan you are on, you may or may not be part of the Essential Health Benefits.  

What are Essential Health Benefits?

A set of basic health care services that health insurance plans in the newly created health insurance exchanges will be required to cover beginning in 2014 and determined by the Department of Health and Human Services.  The Essential Health Benefits should be announced by HHS at the end of 2011.

I want to share this information with friends and family, but I’ve heard them complain about healthcare reform. How can I ask them for support?

The best way to ask for support is to tell your story and make it personal. If you have health insurance that includes coverage for infertility, let them know how lucky you are, as most people do not have this coverage. Infertility is a disease, and impacts a major life function, the ability to reproduce. Your reproductive system is not working as it should, and there are medical treatments to help you, yet you may not be able to use them due to cost. Why should you be denied treatment? Infertility should be a covered disease just like all other medical conditions. This is not about the pros and cons of the Affordable Care Act; the bill passed Congress and now is being implemented. We have this one window of time to get infertility coverage listed as an essential health benefit. Let’s show the world we care about families!

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