If infertility is now a disease, why doesn’t insurance cover it?

In June, the American Medical Association recognized the World Health Organization’s policy that classifies infertility as a disease.

The statement that its delegates voted on: “Resolve that our American Medical Association support the World Health Organization’s designation of infertility as a disease state with multiple etiologies requiring a range of interventions to advance fertility treatment and prevention.”

Would more women be able to conceive if infertility treatments were covered by insurance? Ohio State University Wexner Medical Center

What does that mean to couples dealing with infertility?

The hope is that this will be the first step in pushing insurance companies to expand coverage of  infertility treatments, but it’s going to require patients to advocate for the need, says Dr. Kaylen Silverberg of Austin-based Texas Fertility Center. “We don’t anticipate any rapid change,” he says. “This is such a great opportunity to motivate and mobilize the infertility community.”

Dr. Kaylen Silverberg of the Texas Fertility Center. Credit: Ovation Fertility

He encourages patients to call, email and write letters to their insurance companies, their human resources departments, their legislators and the Texas Department of Insurance to require insurance companies to cover infertility treatment.

Silverberg says that about 65 percent of his patients have some kind of insurance coverage for infertility, but often that only covers diagnosis, not treatment. He likens it to a woman with a lump in a breast getting a mammogram covered by insurance but then not getting any treatment for the breast cancer. “That would never happen,” Silverberg says.

Most insurance companies do cover surgical procedures when there is something structurally wrong such as endometriosis or a fibroid or scar tissue that is causing the infertility. What they don’t often cover are pills or shots to regulate hormones or procedures such as in vitro fertilization.

What infertility treatments have going against them is the public’s perceived cost of them and the belief that infertility treatments automatically means in vitro, he says. Silverberg offers these thoughts:

  • About 70 percent of his patients conceive without needing in vitro. Often it’s something as simple as using ovulation kits or a pill or injectible drug to track, regulate or encourage ovulation.
  • Patients that do need in vitro, can expect to pay $13,000 to $14,000 for one round. That might seem expensive because it’s being paid out of pocket, but it’s not as expensive as many medical procedures such as an appendectomy or gall bladder surgery, which are covered by insurance.

In Texas, insurance companies are required to provide an infertility rider that companies can purchase, but often those feel cost-preventative to employers. States like Illinois, Massachusetts and Hawaii have a mandate to cover infertility, not just offer a rider.

“Let’s make it more affordable for more employers. . . ” Silverberg says. “Let’s have insurance companies do the right thing.” Patients, he says, should be able to use their health care dollars on their disease (infertility) and not just on other people’s diseases that are covered.

What he suspects will happen is that once one insurance company in Texas makes infertility treatment part of the typical plan, others will follow. He saw it happen with employers choosing to pay for the rider to attract employees. First Dell did it then AMD, National Instruments and IBM followed. He saw the same thing happen with Southwest Airlines, which added a benefit to keep employees from going to American Airlines or United Airlines.

“If United (Healthcare) and Aetna started to cover infertility, others would have to,” he says.

In the meantime, he tries to make it as affordable as he can by offering discounts to military, police officers and teachers, by negotiating rates and getting free samples from pharmaceutical companies, and by working with the Fertility Foundation of Texas, of which is wife is president, to secure funding for clients.

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Author: Nicole Villalpando

Nicole Villalpando writes about families in the Raising Austin blog and the Raising Austin column on Saturdays. She also offers a weekly and monthly family calendar at austin360.com/raisingaustin. She tweets at @raisingaustin.

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