Prior to 2020, it was rare to have coverage for fertility treatments like IVF or egg freezing, even when they were considered medically necessary. In a survey about benefits we conducted last year in partnership with Fairygodboss, only 6% of women reported that their employer covered IVF, and only 3% had egg freezing benefits. This echoes the results of a prior report by FertilityIQ, in which over half of those surveyed had no fertility benefits at all.
But as of January 1, all that has changed in New York State. New legislation created as part of the state’s 2020 budget mandates that large group insurance plans cover in vitro fertilization, and that all insurers must cover medically necessary fertility preservation (egg or sperm freezing).
Here’s what you need to know about the new mandate, and how it might affect the cost of your treatment.
What is a “large group insurer”?
In New York State, a “large group” refers to an employer or company with 101 or more employees. The new IVF mandate refers to health plans provided by these employers.
Employees of small and medium-sized companies and those not on a large group plan (e.g. members of professional employer organizations, employees of companies that self-insure—which many large companies do—and those with individually purchased insurance plans) are not guaranteed IVF coverage.
However, the mandated coverage for medically necessary fertility preservation applies to employers and plans of all sizes.
How many IVF cycles are covered?
The new mandate requires insurers to cover the cost of three IVF cycles, including either a fresh or frozen embryo transfer, for patients with a diagnosis of infertility. The mandate uses an updated definition of infertility that specifically mentions donor insemination—therefore including same-sex female couples or single women, who were left out of previous definitions of infertility.
‘Infertility’ means a disease or condition characterized by the incapacity to impregnate another person or to conceive, defined by the failure to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination, or after six months of regular, unprotected sexual intercourse or therapeutic donor insemination for a female thirty-five years of age or older. Earlier evaluation and treatment may be warranted based on an individual’s medical history or physical findings.
The mandate also requires that large group insurers cover up to three cycles’ worth of the medications used for IVF.
What is “medically necessary” fertility preservation?
The new mandate requires all insurance plans, including small group and individual market plans, to cover fertility preservation (egg or sperm freezing) for patients at risk of what’s known as “iatrogenic” infertility, or infertility caused by another medical intervention. This can include those at risk of infertility due to radiation or chemotherapy treatment for cancer, surgery for endometriosis, gender reassignment surgery or treatment, or other medically indicated reasons.
The mandate also requires insurers to cover the medications used in medically necessary egg freezing, as well as storage for the frozen eggs or sperm (with no defined time limit). It doesn’t cover using the frozen eggs, except as part of the mandated IVF coverage for those with an infertility diagnosis (see above).
Who can access this coverage?
Importantly, the new legislation specifically states that this coverage is available to all, regardless of “expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, or personal characteristics, including age, sex, sexual orientation, marital status, or gender identity.” Coverage discrimination based on any of these factors is now prohibited.
What about prior authorization?
This legislation allows insurance carriers to require prior authorization before coverage. A requirement of prior authorization stipulates that doctors and other providers get approval for a treatment or prescription from the insurance company in advance.
How does this affect Extend Fertility patients?
Beginning on February 1, 2020, our doctors will be participating providers with several large insurance companies—meaning our patients may be eligible for IVF or fertility preservation coverage. Stay tuned or contact us for details!
What if I’m still not covered?
While this mandate does a lot to increase access to fertility care in New York State, there will still be some patients who aren’t covered for IVF or egg freezing, including women freezing their eggs without a medical necessity, and infertility patients who purchase their own insurance or are insured by a “small group” employer.
From the very beginning, we’ve made it part of our mission to make fertility care more affordable and accessible even for those without coverage, and that won’t be changing. We offer egg freezing cycles at 40% lower than the national average—$6,500 vs. $11,000—and financing options that offer an easy monthly payment for any of our services. Learn more about Extend Fertility pricing.
Questions about New York’s fertility coverage mandate?
We’re here to help. Contact us to discuss your coverage with a member of our team.