Affordable Care Act DocumentThe Affordable Care Act (ACA) changed the way many Americans receive healthcare. Many were hopeful that it would provide coverage for infertility and the related fertility treatments. Unfortunately, as it stands now, that is not the case. Patients who are considering assisted reproductive technologies, including in vitro fertilization (IVF) and intrauterine insemination (IUI), will still need to pay for these treatments themselves.

So why isn’t fertility treatment covered by the ACA? The answer is found in the definitions set forth by the legislation on what are considered “essential health benefits.”

The federal government included 10 Essential Health Benefits for each state to include in their plans offered on the state’s exchange. These included:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatments
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

As you can see, infertility treatment was not included in this list.

Of course, the states had an opportunity to add fertility treatment into their “benchmark plans,” which is the term used to describe the plans that would include these 10 essential health benefits. These plans are significant because the ACA uses them as the basis for which expenses the federal government will reimburse for the state. The federal government had the states determine what they would and would not cover in their state.

Unfortunately for most infertile couples, these essential benefits were determined by most states using the employer-based plans as a model. As we all know, there is little to no coverage provided by these plans. According to a study by RESOLVE in 2006, only 20 percent of employer-based insurance plans covered fertility treatments. When those plans that didn’t offer coverage were asked why, cost was the reason cited.

While some states do offer some form of coverage for fertility treatments, most don’t, including California. In 2016, California could add more essential benefits to their coverage that would include fertility treatments. It is unlikely, however, because the costs associated with the added services will need to be funded by the state, which has economic issues already.

Unfortunately for the multitudes of couples struggling with infertility, fertility treatments are not covered in most states by the ACA, including California. For now, most couples are paying for their IVF, IUI and other assisted reproductive technology treatments themselves.

Sources:

Cahill, Michael. “What the Affordable Care Act does wrong when it comes to infertility treatment.” www.resolve.org. 23 Jul7 2013. Web. 18 September 2014. http://www.resolve.org/get-involved/the-center-for-infertility-justice/blog/what-the-affordable-care-act-does-wrong.html

“The Affordable Care Act and Infertility.” www.resolve.org. 17 February 2014. Web. 10 July 2014. http://www.resolve.org/get-involved/the-affordable-care-act-and-infertility.html

“Financial Pressures Lead to Fertility Treatments That Rise the Risk of Premature and Multiple Births.” www.medicalnewstoday.com. 22 April 2014. Web 10 July 2014. <http://www.medicalnewstoday.com/releases/275700.php>