Does Medicare Cover Fertility Treatments?
- Does Medicare cover fertility treatments? Learn about the rules governing infertility care through Medicare, what is and isn't covered and other funding options.
The National Institutes of Health states that around 9% of men and 11% of women have experienced fertility problems. This is defined as people who haven’t conceived after 12 months of trying. As the problem is so common, many people seek treatment for infertility.
Medicare may be able to help fund some treatments, but the rules surrounding coverage through the program can be confusing. Understanding when treatments are considered medically necessary and who is eligible can help you make decisions about your future treatment.
Does Medicare Cover Fertility Treatments?
The Medicare Benefit Policy Manual states that “reasonable and necessary services associated with treatment for infertility are covered,” but it doesn’t say exactly what those services are. In practice, this means your doctor has some flexibility because everyone’s condition is unique. The rules and costs of treatment can vary based on your case.
If Medicare does cover your fertility treatment, you still need to meet certain eligibility requirements.
- Expectation of fertility. Fertility tests and treatments are only covered for people if they can reasonably be expected to be fertile. This means that people who aren’t of reproductive age aren’t covered.
- Medically necessary. Treatment can only be provided if the cause of infertility is due to a medical condition. People without a partner and those in same-sex relationships can’t receive assistance getting pregnant unless there’s an underlying health concern.
In general, tests to discover the cause of infertility are covered, both for men and women. If your infertility is caused by another condition, such as endometriosis or PCOS, Medicare is likely to cover treatment, which could improve your fertility.
What Part of Medicare Pays for Fertility Treatments?
When Medicare does cover fertility treatments, most are provided through Part B, which offers doctor and outpatient services. People enrolled in Medicare Part C, also known as Medicare Advantage, can also receive treatments if they’re normally covered by Part B.
What Fertility Treatments Aren’t Covered by Medicare?
For the most part, pregnancy isn’t considered medically necessary. This means that infertility treatments provided by Medicare treat underlying conditions, rather than help you get pregnant. Specifically, assisted reproductive technology (ART) is not covered. This includes any treatment where eggs or embryos are handled, such as IVF.
Prescription drug plans available through Medicare Part D don’t cover fertility drugs such as Clomid, either. Medicare Advantage Plans that include prescription drugs can offer more benefits than original Medicare, so they may cover some fertility drugs. You can check the list of medications covered before choosing a plan, but it’s rare to find plans that provide fertility drug coverage.
Are Fertility Treatments Covered by Medicaid?
As of the beginning of 2020, New York is the only state that covers fertility treatments through Medicaid. That treatment is limited to three cycles of fertility drugs. However, Medicaid does cover treatment of conditions that can impact your fertility, and in many states, Medicaid will pay for some diagnostic tests.
Is Infertility Treatment Covered by Private Insurance?
Currently only 17 states mandate that private health insurance plans offer some form of treatment for infertility, and even in those states, the requirements don’t apply to plans administered and funded directly by employers. If it’s not mandated, treatment is unlikely to be covered because it’s not considered medically necessary.
Testing is more likely to be covered than treatments like fertility drugs and IVF. If your plan does cover treatment, there may be limits on the number of cycles or amount that you can spend. Eligibility can also be limited, as many plans have age restrictions. It's also common for companies to state that you need to have been trying to conceive for a certain period of time, sometimes for as many as 5 years.
Some states place restrictions on treatment based on marital status. They can also say that treatments are only available if they’re medically necessary, which can exclude singles and LGBTQ couples.
How to Fund Fertility Treatments
Most people fund fertility treatments by using their savings or taking out a loan. In addition to a loan from a bank, you may be able to borrow from family or friends. There are loan providers set up specifically for those seeking fertility or medical treatments, and it may be easier to secure funds through these organizations.
There are also grants available to help people who want fertility treatments. There may be stipulations attached to the money, such as using a specific clinic for treatment. Not all clinics accept grant money, so this also limits where you can seek assistance.