Does Medicaid Cover IVF? – Overview
Data from the NSFG (national survey of family growth) shows that many women with Medicaid coverage never use their plans to help them get pregnant compared to those with private insurance.
This is because most US States ideally don’t cover fertility treatment.
As of 2020, studies show that only one State, New York, had policies requiring Medicaid to pay for fertility treatment.
However, as of April 2021, 19 states have passed laws to cover fertility treatment and 13 of those laws include IVF coverage.
Some other states require that Medicaid pay for treatments that may hinder pregnancy and not necessarily IVF procedures.
Some of these treatments include surgery for fibroids, thyroid drugs, abnormal bleeding, endometriosis, or other gynecologic defects causing pelvic pain.
What is IVF?
IVF (in vitro fertilization) is a complex succession of procedures meant to prevent genetic issues or improve fertility so that a patient can conceive and give birth.
IVF is perhaps the most effective form of ART or assistive reproductive technology.
Eggs are retrieved from the ovaries and then fertilized by sperms in a clean room during the IVF procedure. The fertilized eggs are then relocated to the uterus.
One entire IVF cycle takes about three weeks.
IVF can be done using a patient’s eggs and the sperm of their spouse. The process can also be done using the eggs and sperms of anonymous donors if need be.
In some cases, if the patient cannot carry the fertilized egg, a surrogate (gestation carrier) is recommended.
What Are the Eligibility Requirements for Medicaid’s IVF Coverage?
The insurance mandate stipulates that if a State’s Medicaid program covers pregnancy-related benefits, it must also pay for infertility treatment and IVF expenses.
The law also entails health plans covering teachers and State staff also incorporate the same infertility coverage.
A fresh update to the mandate states that infertility is a disease that causes abnormal function of the reproductive system.
As such, the new law aligns its requirements with the medical description of infertility and enables women without partners and women with same-sex partners to be eligible for infertility coverage by Medicaid.
Persons who meet the above description of infertility and the following criterion can receive Medicaid coverage for infertility procedures in some states. The criterion includes:
- If the man is unable to impregnate the woman.
- If the woman is 35 years old and has a male partner, and cannot conceive after one year of unprotected sex.
- If the woman is 35 years old without a male partner and cannot conceive after six attempts of intrauterine insemination under clinical supervision.
- If the woman is 35 years old, and above and has a male partner, she cannot conceive after one year of unprotected sex.
- When the woman is 35 years old, and above without a male partner, she cannot conceive after 12 attempts of intrauterine insemination under clinical supervision.
- When partners are unable to conceive due to involuntary medical sterility.
- When the woman cannot carry the pregnancy to live birth.
- When a woman has been deemed infertile in the past as per the law.
What Does Medicaid Cover concerning IVF Procedures?
The insurance mandate requires that Medicaid pay for three cycles of IVF if the plan includes pregnancy benefits. The procedures included are:
- Treatment that commences when preparative drugs are given to excite the ovaries for oocyte retrieval with the intent of IVF with a fresh and frozen embryo transfer.
- IVF procedures where the embryo is implanted in a surrogate using donor eggs.
- ICSI (Intracytoplasmic sperm injection).
- Assisted hatching.
- Fertility examinations and diagnostics.
- Infertility medications.
- Infertility surgery (when deemed necessary).
- ZIFT (Zygote intrafallopian transfer).
- GIFT (Gamete intrafallopian transfer).
- Ovulation induction.
Does Medicaid Cover Required Services Before An IVF Procedure?
Medicaid will cover services that are deemed necessary before an IVF procedure. Some of these services include:
Physician Clinic Visits
Physician clinic visits involve an appointment with an approved fertility specialist; or reproductive endocrinologist. During the visit, you can table any concerns you have with the physician.
A Hysterosalpingogram is an x-ray procedure that checks the condition of your fallopian tubes and uterus. An abnormal uterine cavity and blocked fallopian tubes can cause infertility.
Before undergoing an IVF procedure, a blood test has to be done to assess the level of FSH (follicle-stimulating hormone) in your body.
This will enable the reproductive endocrinologist an understanding of the quality and number of eggs you may have.
An ultrasound of the pelvic region can provide helpful data on the uterus, endometrial lining, and ovaries during infertility testing.
In addition, specialized ultrasound can be utilized to assess your ovarian reserves and uterine shape in detail.
Which Infertility Prescription Drugs Does Medicaid Cover?
Medicaid will also pay for medically necessary ovulation stimulation medication and medical services allied to the prescription and monitoring of the usage of these drugs.
This only applies to Medicaid enrollees aged 21 to 44 who are battling infertility.
Medicaid will pay for the following ovulation stimulation medication for a limit of three cycles of treatment per lifetime:
What Can Fertility Clinics Do to Make IVF Procedures as Cost Effective as Possible?
To make infertility procedures as cost-effective for patients as possible, fertility clinics can:
- Include the patient in an IVF treatment grant program. For instance, it’s estimated that the combined value of the contributed services for a single Gift of Hope IVF grant stands at around 15,000 USD.
- Create a personalized treatment program for the patient that maximizes their chances of success, all while cutting costs.
- Take advantage of all the benefits available in your Medicaid plan.
- Help you in accessing the best 3rd party financing for IVF procedures so that you can get the treatment you need.
- Ensure you maximize all the prescription medication discounts offered by partnerships between pharmaceutical manufacturers and the clinic.
To sum it all up, the lack of Medicaid coverage for IVF procedures in most US states is a bit confusing because it stands in contrast to Medicaid coverage for family planning and maternity care.
Therefore, while there is plenty of coverage for most services during pregnancy and to prevent pregnancy for low-income individuals, there is almost no help for them to solve their infertility issues via IVF procedures in most US states.
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