Insurance Coverage of Male Infertility

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Federal Health Care Coverage

 

Most federal programs (like Medicare and Medicaid) will cover diagnostic testing for both male and female infertility problems, but will not provide coverage for the actual treatment of infertility issues.  Some specific exceptions exist, such as electroejaculation (EEJ), which is covered by Medicare. 

Tricare is the US Department of Defense healthcare program for active duty service members and their families (and was formerly known at CHAMPUS- the Civilian Health and Medical Program of the Uniformed Services).  Tricare lists the following covered benefits for the diagnosis and treatment of male and female infertility problems:

 

            1) Semen analysis and sperm function testing

            2) Hormone testing

            3) Chromosomal studies

            4) Immunologic studies

 

Services not covered by Tricare include intrauterine inseminations (IUI), in vitro fertilization (IVF), vasectomy and tubal reversals, and sperm donation.  A possible exception to these restrictions exist if an active service member’s infertility was caused by an injury or illness while on active duty.  This exception is similar to the Veteran Administrations (VA’s) announcement at the beginning of 2017 that they will now cover the use of in vitro fertilization (IVF) for spouses of veterans who have had a service-connected disability resulting in infertility that requires IVF to procreate.  Typically, however, the VA does not cover the cost of IVF, but does cover basic male and female infertility evaluations, as well as treatments such as vasectomy reversals (performed at their regional centers) and IUI for women.

 

State Laws for Insurance Coverage of Infertility

 

The Affordable Care Act (ACA), also called “Obamacare”, was signed into law on March 23, 2010.  This sweeping attempt at healthcare reform touched on many aspects of the delivery of medical services in the United States, but did not change the absence of a federal mandate for insurance coverage of infertility problems.  Therefore, individual state laws continue to play the dominant role in defining mandated insurance coverage for infertility services in the United States.  Currently 15 states have some levels of mandate regarding the provision of female infertility services, including AR, CA, CT, HI, IL, LA, MD, MA, MT, NJ, NY, OH, RI, TX, and WV.  Of these 15 states, only 6 states also provide a clear mandate for concurrent coverage of male infertility problems (CA, CT, MA, NJ, NY, and OH).  Also, 2 states (MT and WV) have laws which only specify having vaguely defined “fertility services” as a part of basic health care services, and only for patients enrolled in health maintenance organizations (HMOs).  The level of male infertility coverage in the 6 mandated states varies.  Some states (such as CA, CT, MA, NY, and NJ) specify that both diagnosis and treatment of male infertility problems are covered services, with some exceptions (such as no coverage of vasectomy reversals in MA, NJ, and NY).  Other states, such as Ohio, have much less extensive mandates, covering only diagnostic procedures, and only for patients enrolled in HMO’s (which represented fewer than 1 in 3 Ohio residents in 2016).

 

The healthcare landscape is presently in a state of flux, with the Senate currently working on their own bill to repeal and replace Obamacare, after the House of Representatives narrowly passed their repeal bill on May 4th of 2017.  It will be interesting to see if the increasing recognition of infertility as a true disease process will eventually translate into increased insurance coverage of these problems as the federal and state governments grapple to control rising healthcare costs and concerns about consumer access to quality care.