It’s true: Infertility treatment is often excluded from insurance coverage

About 17.5% of the adult population worldwide, or 1 in 6, experience infertility, according to a new World Health Organization report.

The figures, according to an April 23 news release from WHO about the report, underline the need to increase access to affordable, high-quality fertility care.

In Wisconsin, the political debate is about whether coverage for such treatments should be mandatory in health insurance plans.

"During #NationalInfertilityAwarenessWeek, I’m calling attention to a reproductive health disparity that doesn’t always get the attention it deserves: infertility is treated differently from other illnesses and diseases, and is often excluded from insurance coverage," state Sen. Kelda Roys said April 26 in a Twitter post.

The post included an image with these words: "Being able to parent is a reproductive right. Cost of treatment currently prevents many people from starting families."

Is Roys right about infertility often being excluded from insurance coverage?

Let’s take a look.

When asked to provide backup for the statement, Roys pointed out that infertility is much more common than people realize. 

"Despite how common it is, many insurers do not cover infertility treatment. Instead, patients have to pay out of pocket for what can be very costly treatments," Roys said in an email to PolitiFact Wisconsin. "For example, in vitro fertilization, a common treatment for infertility, can cost thousands of dollars per cycle, and many people require several cycles to achieve a viable pregnancy. Insurance coverage varies state by state, and about 75% of health care plans do not cover infertility treatments."

Roys pointed to an article in the Journal of Health Economics, which said that, nationwide,  only 25% of health care plans cover infertility treatment, and coverage varies significantly by state. 

That article was from 2007, so it is out of date. However, another research article she cited, this one published in December 2011 by Duke University Press, also stated "only 25% of health insurance plans in the United States cover infertility treatment." 

That may have changed in the intervening decade-plus, but there is other evidence suggesting Roys is on point.

First, only 20 states, including neighboring Illinois, require some level of infertility coverage by insurance companies in their state. That means the majority — including Wisconsin — do not have any such requirement. 

According to RESOLVE, the National Infertility Association, the 20 states that mandate private insurers to cover some form of fertility coverage are Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New York, Ohio, Rhode Island, Texas, Utah and West Virginia.

"As of June 2022, 20 states have passed fertility insurance coverage laws, 14 of those laws include IVF (In vitro fertilization) coverage, and 12 states have fertility preservation laws for iatrogenic (medically-induced) infertility," according to RESOLVE.

Sarah Smith, public affairs director for the Wisconsin Office of the Commissioner of Insurance, confirmed that the Badger State "does not mandate coverage for infertility services." 

In his $104 billion 2023-25 budget proposal, Wisconsin Gov. Tony Evers called for requiring health insurance policies and self-insured government health plans to cover diagnosis and treatment for infertility and fertility preservation. 

However, the proposal was among the more than 540 measures stripped from the budget by Republicans who control the Legislature. The GOP is still working on its budget plan.

About 9% of men and 11% of women of reproductive age in the United States have experienced fertility problems, according to the U.S. Department of Health and Human Services.  

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Among married women ages 15 to 49 years with no prior births, about 1 in 5 (19%) are unable to get pregnant after one year of trying (infertility), according to the U.S. Centers for Disease Control and Prevention. Also, about 1 in 4 (26%) women in this group have difficulty getting pregnant or carrying a pregnancy to term. 

The out-of-pocket costs of fertility treatment can amount to well over $10,000 depending on the services received, according to a Sept. 15, 2020 Kaiser Family Foundation report. "This means that in the absence of insurance coverage, fertility care is out of reach for many people."

Also, the Guttmacher Institute, a research and policy organization that focuses on sexual health and reproductive rights, estimated the cost for a successful treatment ranges from approximately $1,000 to $40,000, depending on the services needed. Those services can include fertility assessments and counseling, hormone treatments, surgery, sperm and egg donation, in vitro fertilization and other assisted reproductive technologies. 

Sabrina Corlette, research professor, founder, and co-director of the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy, also said infertility treatment is often excluded from major medical insurance coverage.

"Unless a state mandates it, or in the case of a self-funded employer-sponsored plan, unless the employer decides they want to cover it," Corlette said in an email to PolitiFact Wisconsin. 

The lack of coverage was one reason Wisconsin got a C rating on RESOLVE’s State Fertility Scorecard, which tracks how "fertility friendly" each state is. Factors in the rating include the availability of physicians and specialists, support groups in the state and the number of women who experience difficulty getting pregnant or giving birth. 

Illinois received an A-, as did Connecticut and New York. Massachusetts, New Jersey and Maryland scored A’s. 

Aside from Wisconsin, 12 states had a C grade, including neighboring Michigan.

Roys said "infertility is treated differently from other illnesses and diseases, and is often excluded from insurance coverage." 

Several states, including neighboring Illinois, require some level of infertility coverage by insurance companies in their state, but Wisconsin does not currently have any coverage requirements. And academic research articles have reported that "only 25% of health insurance plans in the United States cover infertility treatment."

For a statement that is accurate and there’s nothing significant missing, our rating is True.