Are Fertility Treatments Covered By Medicare? – Millions of Americans today are struggling with getting or staying pregnant depending on the test results and particular health diagnoses. Doctors or physicians recommend different types of fertility treatment options so that patients can conceive quickly.
Fertility treatments are highly effective and as per reports by the CDC or Centers for Disease Control and Prevention, nearly 1.7% of infants born in America every year are conceived using Assisted Reproductive Technology (ART). Sadly these treatments are highly expensive and cost thousands of dollars and your insurance may not cover these costs. If you’re wondering ‘Are Fertility Treatments Covered By Medicare?’ you are at the right guide.
In this comprehensive guide we will help you delve into the following topics:
- What are the costs of fertility care and treatment?
- Does Medicare cover fertility treatments?
- What are the criteria to cover fertility treatments through Medicare?
- Which fertility treatments are covered by the Medicare program?
- Does Medicaid cover fertility treatments?
- What are the other ways to afford fertility treatments?
Highlights of this Post
Key Takeaways
- Medicare Part B offers limited coverage for fertility treatments, excluding In-Vitro Fertilization (IVF), focusing instead on necessary outpatient care and certain prescribed fertility drugs.
- Coverage under Medicare for fertility treatments is available if you are under 65 with a disability, have ALS or ESRD, or meet specific financial hardship criteria due to reduced income or increased medical expenses.
- To qualify for covered treatments, you’ll need comprehensive documentation, including medical history related to infertility, proof of Medicare enrollment, and prescriptions for medically necessary treatments.
- Explore other insurance options like Medicaid in select states (e.g., New York and Illinois) that provide more extensive fertility treatment coverage, or consider Medicare Advantage plans for additional benefits.
- Utilize HSA/FSA accounts, participate in clinical trials, or seek out non-profit grants and military discounts to help manage the costs of fertility treatments more effectively.
What Is The Cost of Fertility Treatment Without Insurance?
Fertility treatment can be costly including imaging procedures or medications for bloodwork and the single cycle may cost between $15,000 to $30,000 or even more. 1 in 10 U.S. states aged between 15 to 44 have used some form of fertility services to conceive. Among them, nearly 2% have received In-Vitro fertility (IVF) as per the Pew Research Centre.
The insurance coverage for fertility care may vary depending on your state of residence and your insurance provider. Presently 17 U.S. states have laws that don’t have fertility coverage including diagnosis and treatment. These include:
- Arkansas
- California
- Connecticut
- Delaware
- Hawaii
- Illinois
- Louisiana
- Maryland
- Montana
- New Hampshire
- New Jersey
- New York
- Ohio
- Rhode Island
- Texas
- West Virginia.
The coverage varies across the state and the procedures may not be covered fully. Even if you’re living in a state that offers fertility coverage laws, particular insurance providers play a critical role in deciding your coverage eligibility.
Does Medicare Cover Fertility Treatments?
Yes, If you’re enrolled in the Medicare Part B then you can get coverage for necessary services related to treatment for infertility. The Part B Medicare plan covers outpatient care and medically necessary fertility treatments but not In-Vitro Fertilization (IVF).
If your doctor prescribes fertility drugs to address problems with ovulation like clomid, follicle-stimulating hormone, metformin, and bromocriptine then Medicare Part B prescription drug coverage can help you cover your out-of-pocket costs.
Want to know: Does Medicaid Pay for Weighted Blankets? Read our next guide now.
What Are The Common Eligibility Criteria To Get Fertility Treatments Covered By Medicare?
As you know Medicare does not cover IVF or other assisted reproductive technologies you can get some coverage for other fertility treatment.
For instance Medicare Part D Prescription Drug coverage covers medicines that are used to treat infertility however the coverage is limited for fertility-specific medicines. Some of the common eligibility criteria to get fertility treatments covered by Medicare are:
- Must be below 65 years of age and have a disability
- You have Amyotrophic Lateral Sclerosis or Lou Gehrig’s Disease
- You are getting Social Security benefits or any benefits from the Railroad Retirement Board for 24 months
- You have end-stage renal disease.
- You are currently enrolled or qualified for the Medicare program of your state.
- You have a valid prescription, medical records, history of infertility and other documents to demonstrate your medical need.
What Are The Documentation Criteria To Get Fertility Treatments Covered By Medicare?
Medicare beneficiaries who are seeking coverage for fertility treatments need to provide proof of the following documents to get the right coverage:
- Prior authorization or referral forms from their doctor or healthcare provider
- Medical documents documenting their health condition, medical history related to infertility, diagnosis and treatment plan
- Documents of medications prescribed for treatment of fertility (necessary for Medicare Part D coverage)
- Valid prescription from your healthcare doctor that specifies fertility treatment deemed as medically necessary
- Proof of Medicare enrollment card or other official documents that show your Medicare beneficiary.
Which Fertility Treatments Are Covered By the Medicare Program?
A lot of women today are finding themselves in need of fertility treatment due to difficulty conceiving or staying pregnant. Fertility treatments are the best option for having a healthy pregnancy. The fertility treatments generally include the following:
- Fertility drugs
- Intracytoplasmic sperm injection (ICSI)
- Intrauterine insemination (IUI)
- Zygote intrafallopian transfer (ZIFT)
- In Vitro Fertility
- Surgery.
The Original Medicare Program does not cover IVF however there are few cases where Medicare will allow coverage when deemed medically necessary. Even though it is rare to get Medicare coverage for fertility treatment it is not impossible. If your healthcare professional provides a fertility treatment to be medically necessary then you can get it covered through Medicare Part B coverage.
Readers can take a look at our next guide to learn how to get a free fitbit through Medicaid.
Does Medicare Cover In-Vitro Fertilization (IVF) Treatment?
Unfortunately, the Medicare program does not cover In-Vitro Fertilization as fertility treatment. Even though IVF is necessary fertility treatment for a few situations and conditions it is never covered by any form of health insurance program including Medicare. This is because of the medical necessity of the treatment.
IVF is an extensive and expensive process and insurance companies require you to try other ways before they cover IVF treatment.
According to the American Society for Reproductive Medicine, an IVF cycle costs $12,400 on average in America excluding medications and genetic testing.
In other words, you need to exhaust all other forms of utility treatment before your health insurance company considers providing you IVF coverage. Patients are required to provide proof of history of infertility through medical records. The coverage can be limited to those who have had coverage from the insurance for a year or more.
If you are wondering if you can get coverage for IVF then you must contact your state’s insurance coverage laws. If your insurance is provided to an employer then you can contact your HR representative about getting IVF coverage benefits.
Move to our next guide to know how to get free braces with Medicaid.
Does Medicare Cover Intrauterine Insemination (IUI)?
IUI is sometimes covered by Medicare or other private insurance. A few states have laws in place that require insurance to cover the entire or part of IUI procedures. Even in states that have IUI coverage laws, not every patient is reliable to get the coverage.
For instance, if your employer self-insures then they will be exempted from the state laws that need fertility treatment coverage. Moreover, the coverage has limited the number of cycles or limitation on the amount of money that they can get covered. It is necessary to consult your local Medicare office or state fertility treatment coverage laws to determine if you will get coverage for IUI.
Will the Medicare Program Cover Fertility Testing?
Yes, infertility testing that determines your infertility rate is covered by the Medicare program. The cost and regulations for your infertility treatment through the Medicare Part B plan depend on the situation. Your doctor must prove that you are going through infertility due to a medical reason.
The process of diagnosing infertility can be extensive and requires many tests. Women may have different hormone tests, post-coital screenings and thyroid tests to understand their current reproductive system.
The program is likely to cover the treatment if you have a condition causing infertility for instance PCOS or Endometriosis.
The Part B Medicare program covers diagnostic tests as well as treatments for infertility such as the following:
- Sperm analysis
- Genetic testing
- CAT scans
- Testosterone level testing
- MRI scans
- Hormone test
- Thyroid testing
- Testicular biopsies
Based on the results of these tests, training and imaging your healthcare professional will decide your fertility rate. The first and foremost step to give Medicare coverage for fertility treatment is to obtain an infertility diagnosis.
You can read our next guide that will help you learn how to get a free fitbit through Medicaid.
Does Medicare Cover Sperm Analysis?
The Medicare program also covers analysis for diagnosing male infertility from physicians or healthcare professionals who can refer you to a pathology lab. To diagnose male infertility sperm analysis plays a critical role. The Medicare program will cover sperm analysis if your physician or healthcare provider refers you to a pathology laboratory.
The specialized lab will run IVF programs that require thorough testing and can be expensive. As the semen analysis is difficult to prove medically essentially it can be challenging to obtain coverage through Medicare programs. You can contact your healthcare professional to determine if the problem will help you offset the cost.
Do Medicare Advantage Plans Cover Infertility Treatments?
As the Original Medicare Program does not cover infertility generally, the Part C plans are not required to provide this type of coverage. But the Medicare Advantage plans being private insurance policies can help to provide infertility benefits beyond Original Medicare. If your Part C plan covers infertility services then there may be coinsurance or copayment costs for your medical care.
You need to have a medical condition contributing to your infertility to qualify for infertility treatments for Medicare Advantage plans. You need to check your Medicare Advantage Plan or Medigap coverage to see if the fertility drugs and treatments are covered. You can also compare Medicare Advantage or Medigap and Part D plans to learn which one suits your needs.
Our next guide will throw light on how to get a free breast pump through Medicaid.
Does Medicare Cover Fertility Treatment Drugs?
Prescription drug coverage does not comprise fertility drugs even if your healthcare professional prescribes the drugs. Medicare Part D or Prescription Drug Plans also known as Medicare Advantage plans with prescription coverage do not extend to coverage for fertility medications.
Beneficiaries have to cover the cost of the fertility prescription 100% out of pocket. Even though the Medicare Part D does not include a fertility prescription the coverage may be possible shortly. This is because Medicare coverage is changing constantly and new drugs are becoming available regularly.
Following are the common fertility drugs that are excluded from the Medicare Part D formularies with infertility diagnosis:
- Human menopausal gonadotropin
- Follicle-stimulating hormone
- Gonadotropin-releasing hormone
- Bromocriptine
- Metformin or letrozole.
You can also learn how to get a free YMCA membership with medicaid by reading our next guide here.
Does the Medicaid Program Cover Fertility Treatment?
Yes in many states Medicaid covers the treatment but major state guidelines and regulations do not provide coverage for fertility treatments. As of February 2024, only two US states: New York and Illinois cover fertility treatments through Medicaid programs.
A few more states provide at least one Medicaid program that covers infertility diagnostic services; however, the range of diagnosis covered may vary. These states include:
- Hawaii
- Georgia
- Massachusetts
- Michigan
- Minnesota
- New Hampshire
- New York
- New Mexico.
New York Medicaid covers up to three cycles of fertility medicines including oral ovulation-enhancing medications. The Illinois Medicaid program covers fertility preservation prior to covered medical treatment that leads to infertility such as cancer.
How To Get Assistance Finding Medicare Coverage For Fertility Treatments?
The benefits of the Medicare program may not extend far for those who are looking for fertility treatment coverage but that doesn’t mean you will not have other healthcare benefits. If you need a Medicare Supplement plan or require Medicare fertility coverage then having a Medicare Supplement Plan will reduce your out-of-pocket costs.
While enrolling in the Medigap plan can reduce your Medicare Part A&B costs significantly the Medicare Supplement insurance will help you to cover the cost that you would otherwise pay such as Part A deductible and Medicare coinsurance. If your fertility treatment is successful you can expect the Medicare program to cover pregnancy and childbirth as well.
Readers can take a look at our next guide to know if they can get pediatric diapers covered by Medicaid.
How Can You Make Your Fertility Treatment More Affordable?
Making fertility treatment more affordable is possible through the following ways:
- Package Deals: A lot of fertility clinics provide discounted rates when you commit to multiple cycles and wish to pay upfront. You can ask about a package deal that appeals to you.
- HSA or FSA Account: You can take advantage of your Health Savings Account or Flexible Spending Account to save money on fertility treatments.
- Participate In Clinical Trials: Many research studies test new fertility treatments and pay for your treatment method if you enroll such as FindMeCure or Clinicaltrials.gov.
- Check For Financial Assistance Program For Those Who Have Cancer: If cancer is impacting your fertility then you can take the help of organizations that offer financial assistance to make parenthood possible for you. For instance, the Expect Miracles Foundation provides family-building grants that help cancer and cancer survivors in many ways.
- Look For Military Discounts: In some cases, military members, veterans and their spouses can get grants or free fertility medications. There are fertility clinics that offer these discounts on treatments. For instance, pharmaceutical companies like Emd Serono and Ferring give free fertility medications to eligible veterans and their spouses.
- Fertility Grants From Nonprofit Organizations: Many nonprofit organizations offer fertility grants and the primary eligibility criteria are based on your household income or location. Some of the affordable fertility treatment options are:
- ANEDEN Gives – Fertility Grants
- Baby Quest Foundation Grants
- Cade Foundation Grants
- Chicago Coalition for Family Building
- Cleveland Clinic – Ohio Hospital Care Assurance Program (HCAP)
- The Fertility Foundation of Texas
- Footprints of Angels
- The Hope for Fertility Foundation National Grant
- The JFCS Fertility Fund: A Gift From the Heart
- Nest Egg Foundation Grant
- Parental Hope Family Grant
- Samantha’s Gift of Hope
- The Samantha and Kyle Busch Bundle of Joy Fund
- Starfish Infertility Foundation.
Conclusion
In conclusion, the fertility rates in America have been decreasing over the previous years. Several women of childbearing age are struggling with infertility as a result of health conditions. Those who are wondering: ‘Are fertility treatments covered by Medicare’ would be pleased to note that a few Medicare programs (depending on their state of residence and eligibility) can help them cover costs for fertility treatments or other assisted reproductive treatments. Medicare which is known to be a health insurance program for senior citizens who are 65 or above can also provide coverage for health and fertility concerns. Couples dealing with infertility must get medical coverage through Medicare Part B and Advantage plans. You need to make sure your healthcare professional considers fertility treatment as a medically necessary option for you to qualify for Medicare coverage.
Head to our blogs at Get Government Grants to avail free resources and government programs for low-income families. Our guide has numerous supportive programs and names of organizations that help people in times of need.
