According to the numbers provided by the Centers for Disease Control and Prevention (CDC), roughly 6.1 million women aged 15 to 44 years old have trouble getting or staying pregnant. As such, many of them turn to fertility treatment options to help them conceive. They can either have fertility medications, in-vitro fertilization (IVF), intrauterine insemination (IUI), gamete intrafallopian transfer (GIFT), intracytoplasmic sperm injection (ICS), zygote intrafallopian transfer (ZIFT) or surgery. Based on the reports from the CDC, these fertility treatments are highly effective, with about 1.7% of babies born in the U.S. through assisted reproductive technology. Unfortunately, these treatments are expensive, and insurance wouldn’t cover these costs.
If you are looking at Medicare to help you with the costs of fertility treatments, here are some of the things that you should know:
Medicare Coverage Conditions
If you are less than 65 years old and currently have Medicare benefits for a disability, then you may qualify provided that you have Medicare Parts A and B coverage. Medicare can cover the necessary services for fertility treatments, such as consultation and patient care. However, Medicare will not pay for IVF treatments.
Medicare Supplement Insurance Can Help
The coverage for IVF treatments will depend on your location. While Medicare will not pay for the costs of IVF treatments, patients who are struggling can benefit from getting Medicare Supplement insurance from providers like Humana. Medigap or Medicare Advantage plans are usually sold by companies to fill in the “gaps” left by Medicare coverage. Part B can cover fertility drugs, and Medicare Supplement Insurance can cover the rest of the cost like the ones you would likely spend on IVF.
Medicare Part B and C Can Help with Costs
Before Medicare can pay for your fertility treatments, your doctor must present proof that the fertility treatment is medically necessary. Note, however, that the ruling and costing are unique for each case. In general, if Medicare Part B will shoulder the costs, Part C or Medicare Advantage would pay for the expenses.
Medicare Can Pay for Sperm Analysis
Part of diagnosing male infertility is the sperm analysis. If your doctor refers you or your partner to a pathology lab for semen analysis, Medicare will pay for it. However, if the doctor requires comprehensive testing and refers you to a specialized laboratory with IVF programs, Medicare may not pay for it. Note that these specialized labs are far more expensive than conventional labs.
Fertility Treatment Coverage Conditions Vary by State
Each person may have a different case from another. As such, fertility treatment coverage varies per case. In general, fertility treatment coverage depends on where you live. Currently, 16 states have existing laws that mandate fertility coverage. These states include:
- New Jersey
- New York
- Rhode Island
- West Virginia
Fourteen of these states require insurance companies to cover infertility treatments, while both Texas and California only require insurance providers to offer coverage. Note that the coverage does not mean that you will not pay for anything. If you have private coverage, you still have to shoulder the copay expenses. Plus, you have to provide proof that you meet the criteria for infertility to qualify for coverage. You will likely be eligible if:
- Your age is 35 years and older and you are unable to bear a child for six months, or pregnancy resulting in a live birth happening after 12 months.
- You don’t get pregnant after having unprotected intercourse for one year.
Part D Drug Plans Don’t Pay for Fertility Drugs
Medicare Part D is often used by beneficiaries to reduce the cost of prescription drugs. Unfortunately, they do not cover fertility drugs. However, there is some information regarding Part D formularies, which may include some medications under specific plans. Some would cover fertility treatment medications provided you buy from a recommended pharmacy. It won’t do any harm to ask an agent about your insurance plan to see whether they can make adjustments even to pay at least a portion of your expenses.
The Bottom Line
Given all these details, one can surmise that it helps to have supplemental insurance to help pay for the costs of fertility treatments, primarily for IVF, which is the most effective of all. Getting one can prove to be beneficial. However, it is still best to choose the provider wisely, depending on your needs. It would also be best to check whether your state has laws about fertility treatment coverage if you live in any of the states mentioned above.