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Does Health Insurance Cover Fertility Tests

Male & Femal Fertility Test Cost And Insurance Coverage

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Fertility testing is recommended for couples after a couple remains unsuccessful at becoming pregnant for one year. Both the partners are required to undergo a thorough medical and physical assessment since 40% of cases involve male factor infertility while another 40% involve female factor infertility. Another 10% account for issues with both partners while the remaining 10% remain undetermined.

The male and femal fertility test cost varies based on the type of procedure involved and the extent of invasiveness.


  • Insurance Law for Fertility Test Cost
  • Is The Time To Be Your Own Biggest Advocate

    Its incredibly important you do everything you can to understand your coverage and give your family building dreams a chance to come true. Now that we’re in the midst of open enrollment, it’s a great time to get on the phone and ask these necessary questions.

    Be your best advocate, and lets start the journey now. Cheers to your future!

    Want to make the most of your coverage in 2022?

    Best Fertility Insurance Companies

    Why We Chose It: United Healthcare is our overall pick for fertility insurance because of its expansive network, solid reputation, and coverage for infertility services, including ovulation induction, insemination, and Assisted Reproductive Technologies.

    • Available in all 50 states

    • Telehealth available

    • A smartphone app that integrates with medical records

    • Infertility treatments likely limited to 19 mandated states

    • IVF may not be covered

    • Not available in some counties

    • More expensive than some competitors

    For couples trying to conceive, having an insurer’s safety net that covers infertility treatments is invaluable. United Healthcare took our position as the overall fertility insurance choice with their giant provider network, supreme reputation, and coverage for a range of infertility treatments.

    United Healthcare has a network of more than 1.3 million doctors and 6,500 hospitals and other facilities nationwide, including in the 19 states with mandated fertility insurance coverage laws. They have an A rating for financial stability from AM Best and are rated 4.0 or better out of a maximum of 5 for six of their health insurance plans in the National Committee for Quality Assurance ratings.

    The following services are excluded from coverage:

    • Cryopreservation of the fertilized embryos
    • Donor eggs
    • Ovum or ovum bank charges
    • Sperm or sperm bank charges

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    Does Your Insurance Provider Offer Infertility Coverage

    Seeking infertility treatment in Los Angeles can be a stressful experience. Because the California infertility mandate is minimal, many insurance providers dont cover infertility coverage. The only requirement in the mandate is that health insurance providers must offer at least one policy that includes infertility coverage, and make that plan available to everyone without discrimination.

    That being said, the mandate does not require providers to include In Vitro Fertilization as part of their coverage, nor does it require employers to offer those inclusive plans to employees.

    To qualify for infertility treatment under Californias mandate, patients must have a medical condition that causes infertility, as diagnosed by a physician, or be unable to conceive or carry a child to term after one year or more of unprotected sex.

    As we enter the open enrollment season for private employers, it might be a good time to look into your options and choose a plan that has the infertility coverage you need. Insurance plans can vary greatly in their requirements and definitions, so doing some research ahead of time is helpful. Before you get started, find out what each policy offers when it comes to infertility testing and treatments.

    Types Of Health Insurance Plans

    Does Health Insurance Cover Fertility Treatments

    You will find two different kinds of medical issues or illnesses one which requires hospitalisation, or surgery and medication for recovery, and two which could be life-threatening even with treatment.

    There are two different types of health insurance plans:

    a) Defined Contribution Health Plans

    The health insurance coverage you have for your entire family and the Mediclaim cover you receive through your employer fall into this category. Defined contribution means the premium cost for health insurance is defined. However, the benefit will depend on the actual expense.

    The cost of IVF and similar treatments, if covered, will fall under this type of health insurance plan.

    b) Defined Benefit Health Plans

    A little less popular, yet equally important, these plans help you against life-threatening illnesses like cancer. This is why they are also called critical health insurance plans. You can buy a critical health cover as a rider with your term or health insurance plan.

    These health plans have a defined benefit amount, meaning you will receive a fixed sum upon diagnosis of a covered illness. The amount you spend on treatment doesnt affect your benefit from the plan.

    Since IVF treatment is not a life-threatening situation, critical health plans are unlikely to cover this cost or condition.

    You can cover maternity and related expenses with a family floater health cover . These plans will also cover the newborn from day one.

    With critical health insurance you have a few options:

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    The Affordable Care Act: Good News And Bad News

    The passage of the Affordable Care Act sometimes called Obamacare, mandates that health insurance companies provide the same set of essential health benefits, including outpatient care, hospitalization, emergency services, prescription drugs, maternity and newborn care, preventive and wellness services and pediatric services. They can also provide additional health benefits if the plan chooses.

    The bad news first: Infertility treatment is not one of the essential health benefits mandated by the ACA. If your health insurance did not cover fertility treatments before, it does not have to now. Now for the good news. Infertility is considered a pre-existing condition. Before the ACA, you could have been denied insurance coverage completely because you had a pre-existing condition. As of 2014, an insurance company cannot refuse to cover you because you are diagnosed as infertile.

    Psychological Impact Of Infertility

    Infertility doesnt just affect couples in a physical way, it may also cause emotional pain. There are high highs and low lows. Its not uncommon to experience anxiety or depression during this time in your life, particularly when others announce a pregnancy. Remember, another persons ability to get pregnant may not necessarily take away from your own. The process of trying to conceive may become all-consuming with baby thoughts on your mind all the time. This stress may take a toll. Lean on friends and family, join a support group or find a professional to help you process your feelings and cope with emotions while experiencing fertility treatment . If you may feel emotionally and physically spent, your relationship may be suffering or you may be having trouble sleeping, you may want to consider talking to your doctor about possibly taking a short break from the demands of appointments, tests and treatments.

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    The State Of The States

    • Is your plan fully insured or self-insured? In a fully insured plan, the company pays a premium to the insurance carrier. That premium is fixed for a year, based on the number of employees enrolled each month. In a self-insured plan, the employer provides benefits using the company’s funds. A fully insured plan is required to follow state law, but self-insured plans can opt out.
    • Does your plan have a “greater than 25” policy? If an employer has below a certain number of employees, they may not be required to provide coverage.
    • Was your employer’s plan written in the state with the infertility law? In general, in order for the law to be honored, it must have been written in the state with the law in place.

    The Basics Of Understanding Fertility Insurance Coverage

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    Most insurance plans will cover infertility diagnostic testing, but it is important to determine whether you have coverage for diagnosing infertility or coverage for up to the diagnosis.

    • If your insurance plan provides coverage for diagnosing infertility, this typically includes coverage for all services performed in the diagnostic process regardless of when they are performed.
    • If your insurance plan provides coverage for up to the diagnosis, this is typically coverage for one visit using an infertility diagnosis, but the entire diagnostic process can take more than one visit. In this case, you may want to take advantage of that one visit with our Austin fertility doctors and request to have all testing possible at that initial visit.

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    Not Every Fertility Clinic Is Covered

    Some insurance carriers will work only with fertility clinics that meet certain criteria.

    What accreditations and experience should you look for?

    They may require the fertility program to be a center of excellence. It is just as likely that an approved clinic will report to the Society for Assisted Reproduction Technology. SART is an independent organization that lists the annual pregnancy success rates of participating fertility clinics across the country.

    Other accreditations and licenses may be required, such as that offered by the College of American Pathologists for laboratories.

    It may be obvious, but its important that you like your doctor. And part of liking your doctor is the experience and training that they have gained. Dont settle for less than a board-certified Reproductive Endocrinologist, the highest possible standard.

    Surgery For Male Infertility

    • If you have a blockage in the tubes that take sperm from your testicles to your penis, it can affect your fertility. This can also happen if the tube at the back of each testicle which stores sperm gets blocked. You may be able to have an operation to remove the blockage and restore your fertility.
    • If you have varicoceles and theres no other reason for your infertility, your doctor may suggest surgery. Although the National Institute for Health and Care Excellence doesnt recommend this as a treatment. But some research suggests that surgery may possibly improve your chances of pregnancy, although theres not enough evidence to show it increases the chance of having a baby naturally. Your doctor will discuss this further with you.

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    Insurance Companies That We Contract With For Fertility Coverage & Benefits

    The Reproductive Medicine Group participates with the following insurance companies:

    Aetna: Basic, PPO, POS, HMO, EPO, MC . Please note if you have any Aetna product other than a PPO, you must join the Aetna Infertility Program by calling 1-800-575-5999 before scheduling appointments at our facility. RMG is a member of the Aetna Institute of Excellence network.Baycare: PPO

    The Federal Employee Retirement Income Security Act

    Does Health Insurance Cover Fertility Treatments

    If your workplace is self-insured, you should remember that your business is subject to the Federal Employee Retirement Income Security Act. State laws do not apply to self-insuring companies because ERISA prevents states from being able to regulate self-insured companies. Although they don’t have to comply with state mandates, they can voluntarily provide IVF benefits.

    In the future, RESOLVE believes the federal government can pass laws requiring insurance coverage for diagnosis and treatment of infertility. This legislation would supersede ERISA and require more companies to offer infertility insurance to their employees.

    The National Pregnancy Discrimination Act guarantees some pregnancy-related services in most health care plan benefits. Infertility treatments, especially assisted reproductive technologies, are not insured under this act and their availability is extremely limited in the United States.

    Only one in five self-insuring companies provide infertility treatments that vary in their reimbursement limits, comprehensive coverage, and eligibility requirements.

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    Fertility Coverage By State

    The state you live in may have laws requiring health insurance companies to provide fertility coverage as well. Sixteen states currently require that fertility coverage is included in health plans, and five states require fertility coverage for individuals who have medically induced infertility. Medically induced infertility can occur in individuals who have gone through chemo. For a list of fertility coverage by state, click here.

    For most couples, the thought of needing to go through fertility treatment to start their family may be tough to face, although worth it in the end. For other same sex-couples or future single parents seeking egg or sperm donors to help for growing a family, it can be a ray of hope. The good news regarding insurance coverage is there seems to be an increasing trend for the need for fertility treatment. This means more and more people are using medical insurance to pay for treatment, and more and more insurance companies are being billed by fertility clinics. There will be families who are denied coverage as well due to their plan limitations. We as patients need to talk to these insurance companies who have very limited coverage for fertility treatment. We need to advocate for ourselves and explain the importance of insurance coverage. Infertility is a diagnosis that is difficult to navigate and understand for patients. They deserve the right to seek treatment without the worry of astronomical bills.

    How Does My Insurance Coverage Work For Fertility Treatments

    Health insurance coverage is a complicated subject. Coverage for infertility treatment varies from plan to plan and from insurance company to insurance company. Florida law does not mandate your insurance company to cover fertility evaluation or infertility treatment costs.

    It is very important for you to research what your insurance plan covers in terms of evaluation and treatment of infertility, either online or by calling the insurer or benefits representative, or both, before your first visit.

    We understand that dealing with insurance companies about your infertility insurance coverage may be intimidating at first glance. To protect yourself from fees that may not be covered by your insurance plan, you should obtain written verification of your benefits.

    Insurance companies have specific guidelines to help you determine the extent of your fertility benefits. They are required to provide you with this information. Typically, the information is given only in response to specific questions asked by the insured and some important information may be omitted unintentionally.

    If infertility is included in your policy coverage, the following questions should be asked:

  • Is my policy for diagnostic service only?
  • Is Diagnostic Code N97-9 covered?
  • Do I have coverage for the treatment of underlying conditions that may be the cause of my infertility?
  • Is CPT codes 58322 & 58323, for IUI, with diagnosis code V1 covered?
  • Have I met my deductible?
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    Can You Choose Gender Ivf

    Sex selection is only possible using IVF embryos. The term sex selection is preferable to the past term of gender selection. Gender is increasingly known as how a person identifies sexually. Whereas a childs sex is a genetic identification of an inherited male XY chromosome pairing or a female XX chromosome pairing.

    Pregnancy Is Not A Preexisting Condition

    Fertility Treatments: What does your insurance cover?

    Once you achieve pregnancy, your insurance will provide coverage for your services under your maternity benefit. If maternity coverage is excluded from your policy, your services will not be covered with the exception of a pregnancy complication. Most plans will cover any pregnancy complication, such as a miscarriage or tubal pregnancy. Be sure to carefully research this benefit.

    Contact us to learn more about understanding fertility insurance coverage or to schedule an appointment with one of our Austin fertility doctors.

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    When Infertility Is Caused By Another Underlying Medical Condition

    If your infertility was caused by another underlying medical condition, your insurance provider will consider these medical conditions separate from your infertility benefit. If you are diagnosed with a medical condition, such as endometriosis or a fibroid, your insurance will likely provide coverage for services provided to diagnose and treat these conditions as any other illness.

    In some circumstances, your insurance may argue that you would not have been treated for these conditions if you had not been attempting pregnancy. In these types of cases, it is within your right to argue otherwise.

    Anytime you have a preexisting clause in your insurance policy, be sure to research your coverage carefully. A preexisting clause will exclude any condition you were previously diagnosed with, within a certain time frame.

    Final Thoughts On Infertility Insurance

    Navigating infertility insurance can be complex. Each provider has its own criteria for infertility insurance, in addition to state laws that may address infertility issues very differently. You should definitely check with your insurance provider on the infertility insurance coverage before proceeding with any tests or treatment because coverage can be tricky.

    If you or your partner is having trouble getting or staying pregnant, infertility insurance can be a great option to afford fertility treatments or at the very least, get the answers you need.


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    Should I Think About Freezing My Eggs

    Even women who arent planning to get pregnant right away might consider signing up for a fertility test. One in eight people who do want to have children are diagnosed as infertile. Its better, and easier, to know as early as possible what options you might pursue.

    If you are in your 30s, the ticking of the biological clock coincides with a decline in the quality of your eggs. Its true for everyone, and knowing if there are other issues will help you make plans for the day you do decide you want to become pregnant.

    Treatment for infertility requires a commitment of time, money and mental and physical resources. If you do have fertility issues, knowing earlier than later will help you prepare to the fullest possible extent.

    Diagnosis And Treatment Services

    Does Health Insurance Cover Fertility Treatments

    Infertility is most commonly defined1 as the inability to achieve pregnancy after 1 year of regular, unprotected heterosexual intercourse, and affects an estimated 10-15% of heterosexual couples. Both female and male factors contribute to infertility, including problems with ovulation , structural problems with the uterus or fallopian tubes, problems with sperm quality or motility, and hormonal factors . About 25% of the time, infertility is caused by more than one factor, and in about 10% of cases infertility is unexplained. Infertility estimates, however do not account for LGBTQ or single individuals who may also need fertility assistance for family building. Therefore, there are varied reasons that may prompt individuals to seek fertility care.

    Figure 1: There Are Multiple Reasons Someone May seek Fertility Assistance

    Table 1: Overview of Common Fertility Services
    Diagnostic Services:
    SOURCE: ACOG. Evaluating Infertility. 2017 ACOG. Treating Infertility. 2019 American Society for Reproductive Medicine. Infertility: An Overview. Patient Information Series. 2017

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