IVF, IUI, or fertility medications denied? 19 states mandate fertility insurance coverage.
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State mandates and federal protections make fertility treatment denials highly appealable. Here is what you need to know.
States including Illinois, New Jersey, New York, Massachusetts, Maryland, Connecticut, and Rhode Island require insurers to cover IVF and fertility treatments. Mandate scope varies — some cover unlimited IVF cycles, others set cycle limits or require prior infertility diagnosis. If you live in a mandate state, a denial may be outright illegal under state law.
Section 1557 of the ACA prohibits sex discrimination in health coverage. Courts have found that denying fertility treatment coverage solely to same-sex couples or based on marital status may constitute unlawful discrimination. Additionally, ACA plans cannot impose lifetime or annual dollar limits on essential health benefits that include reproductive care.
Many denials hinge on how your insurer defines "infertility." ASRM (American Society for Reproductive Medicine) defines infertility as failure to achieve pregnancy after 12 months of unprotected intercourse (or 6 months for women over 35). If your insurer uses a more restrictive definition, or denies based on relationship status rather than medical diagnosis, the denial is challengeable.
Some plans or state mandates impose age caps or per-cycle limits on IVF coverage. However, these limits must be applied consistently and in writing in your plan documents. If your insurer applies an undisclosed limit, or applies age restrictions that do not appear in your Summary Plan Description, you have grounds to appeal citing the plan's own terms and ERISA disclosure requirements.
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