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What the Affordable Care Act does wrong when it comes to infertility treatment 

Posted by: Michael Cahill at July 23, 2013 
Category: Essential Health Benefit 

Beginning in 2014, the major provisions of the Affordable Care Act (ACA) will finally become law. The sweeping health care reform legislation, more commonly referred to as "Obamacare," aims to completely overhaul the American health system.

However for the one in eight couples of childbearing age in the United States who have infertility problems, the ACA might not be that beacon of hope the president and his administration have held it up to be. When the legislation was proposed more than three years ago, many of these couples thought it might herald in a new age of accessibility and affordability for infertility treatments.

Now though, with less than 100 days to go until the state health insurance markets open, we have a better idea of how those couples will be affected. And sadly it’s not very hopeful. 

According to a 2006 study by RESOLVE: The National Infertility Association, only 20 percent of employer-sponsored health insurance plans offer coverage for infertility treatments. Of those businesses surveyed who did not offer coverage, cost was cited as the number one reason.

With insurance coverage such a barrier to infertility treatment, the question is will the Affordable Care Act mandate that insurers cover it? The answer is no.

Overall the Affordable Care Act will likely improve the American health system, if only in certain areas. It will eliminate pre-existing conditions and set limits on how much insurers can charge for premiums. Also gone will be lifetime and annual spending caps for any new insurance plans sold after the law takes effect. 

Sadly though, mandated coverage for infertility treatment is not explicitly spelled out under the ACA. The law only outlines ten “essential health benefits” categories that must be included in all the health plans sold through the state health insurance marketplaces. These categories include:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance abuse disorder services,  including behavioral health treatments
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

So where does infertility treatment factor into all this?

While the ACA does not require insurers nationwide to cover specific treatments and procedures, states were given the responsibility to choose their own state’s essential health benefits plan and can decide to include infertility treatment as part of their state’s "essential health benefits" (EHB) of its "benchmark plan."

Benchmark plans will serve as the model for health insurance plans sold in the state insurance marketplaces. That means that the benefits included in these benchmark plans will be the benefits included with all plans sold at the marketplaces. They’re based on 2012 plan designs and may include any benefits mandated by state law that were on the books as of December 31, 2011.  

The Obama administration’s reasoning behind the rules to allow states to choose their essential benefits was so that it would make local transition to the ACA easier. But as a potentially severe side effect, this also means that coverage for essential benefits will vary greatly depending upon where you live.

Many states have chosen their Benchmark Plan, such as Massachusetts and Maryland. Both of these states currently mandate coverage for infertility, and their Benchmark Plan thankfully includes the infertility mandate. To date we do not know of any state without an infertility mandate that has chosen to now add infertility as an essential health benefit. 

The 2011 cutoff for benefits included in benchmark plans is also a cause for concern. Under the rules issued by the Obama administration, any state-mandated insurance benefit added after 2011 will not be subsidized by the federal government as part of the essential benefits come 2014. So even attempts in some states to add a new infertility mandate really won’t help anyone. 

Grandfathered Insurance Plans

Living in a state that mandates infertility coverage is still not a guarantee that it will be covered by your insurer next year. If you are participating in your employer’s health plan and it currently does not cover infertility treatments, then you should check with your Human Resources department to see if they are planning to “grandfather in” their health plan next year.

Under the Affordable Care Act regulations, an older insurance plan that does not meet the new requirements of the law (such as essential benefits), can continue to be offered so long as the employer does not make any major changes to it.

We are watching closely the eight states with an IVF mandate (Arkansas, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey and Rhode Island) to see how they implement their EHB and administer their exchanges in 2014 and 2015. 

There’s no doubt that the Affordable Care Act still has a long way to go. With all the controversy surrounding the law, its major implementation next year will likely be a bit rocky. And 2014 and 2015 have clearly been stated as “trial” years for the state exchanges and EHB’s. In other words, changes could still occur for the 2016 plan year that impact infertility coverage.

According to our current system, which the Affordable Care Act does not opt to change very much at all, insurance companies need to make a profit in order to stay afloat. Covering infertility treatments will still be difficult while insurers do not recognize infertility as a disease that needs to be covered like all diseases. 

While insurers continue this trend, health plans will likely opt to continue to exclude coverage for infertility treatments. Unfortunately this is bad news for infertile couples looking to start a family. They may end up with no other option but to pay out-of-pocket for treatment or go with very expensive plans if they want coverage.

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.



Submitted by babyblues at: December 12, 2014
I am devasted by this!! :( thank u for all the information Obama should had included mandatory infertility coverage for every state!! :( please keep us updated



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