Editor’s note: This story was updated on Nov. 7 to include updated information provided by OPM.
Insurance coverage for infertility treatments has been growing among carriers who supply millions of federal employees and their families with health care each year, though there remains some lingering costs to watch out for.
This year, the Office of Personnel Management, which oversees the Federal Employees Health Benefits program, stipulated that all carriers will cover procedures and associated drugs for intrauterine, intracervical insemination and intravaginal insemination. Carriers are also instructructed to cover drugs for three cycles of in-vitro fertilization each year, marking a significant step forward on covering an expensive procedure.
How exactly plans are doing that, though, can vary. And if you expect not to pay anything out of pocket, you’ll likely be disappointed.
“One thing that’s true is that just because a plan says they’re going to cover something, there is still an enormous amount of out-of-pocket cost,” said Kevin Moss, a benefits expert for Consumers’ Checkbook, in an interview. “Often their coverage is at a higher coinsurance. And what that cost share is for you varies greatly by the plan.”
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As federal employees and their families prepare for open season on Nov. 13, it’s a near guarantee that at least some will be looking to artificial reproductive technology this year. In the U.S., clinical infertility impacts roughly 12% of women, according to the National Institutes of Health.
In the past, FEHB plans have covered the diagnosis and some limited treatment of infertility, but that has often excluded IVF. However, recent pressure from lawmakers and advocacy groups have urged the program to expand coverage of treatments and bring it in line with what some private sector companies offer.
This year, OPM says 14 carriers will offer 24 coverage options for IVF in particular.
Those are: Blue Cross Blue Shield Service Benefit Plan (standard option only); Baylor, Scott and White Health Plan (all options); Calvo’s SelectCare (all options); Foreign Service Benefit Plan; Geisinger Health Plan (all options); Health Alliance HMO; HMSA plan (all options); Kaiser Permanente, Hawaii (all options); all options under Sentara Health Plan (formerly Optima Health Plan); Presbyterian Health (all options); Priority Health (all options); Rural Carrier Benefit Plan (all options); Sentara Health Plan, Northern Virginia (new for 2024); and UPMC Health Plan (all options).
Six plans also offer discounted or negotiated rates for procedures that aren’t otherwise covered, including the BCBS Service Benefit Plan, MHBP, Rural Carriers Benefit Plan, CDPHP, Health Alliance HMO, and Anthem Blue Cross Select HMO
“As a longtime proponent of better, more equitable coverage for infertility treatments, I am thrilled that OPM has taken this significant step forward,” said Virginia Democratic Rep. Gerry Connolly in a statement. “Federal employees, like every American, should have the right to start and build a family on their terms.”
Employees should be wary that other artificial reproductive services, like donor egg storing and freezing, and surrogacy, remain uncovered.
Coverage requirements
Now, here’s the fine print: infertility coverage will often require some kind of prior authorization, regardless of the plan, Moss said.
That usually requires making a doctor’s appointment and getting that physician’s certification of the procedure before coverage can kick in.
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“How arduous the pre-authorization process is is a function of the plan’s complexity and what documentation (if any) the insurer has about your circumstances,” such as age, previous attempts to conceive, testing or diagnoses, according to FertilityIQ.
For example, Blue Cross Blue Shield is offering a major benefit this year of $25,000 annually for reproductive procedures for members. However, they must meet the plan’s definition of infertility and obtain prior approval.
Coverage can also depend on where you live. As of September, 21 states, plus Washington, D.C., passed fertility insurance coverage laws, 15 of which include IVF coverage.
“If you have a happen to be in the state of Hawaii, you are in the best possible position because of a state law that was passed,” Moss said. “HMSA and Kaiser in Hawaii have covered IVF, and they’ve covered it for many years.”
Plans may also rely on different definitions of infertility that could impose eligibility requirements on a patient. Lawmakers previously called on OPM to ensure the way infertility is defined does not result in discrepancies in coverage, especially for same-sex couples.
This month, the American Society for Reproductive Medicine published a new definition of “infertility” that recognizes medical, sexual or reproductive history, and the need for other medical interventions like donor embryos.
Open season 2024
Open enrollment for federal employees and their families begins Nov. 13 and ends Dec. 11. Many plan brochures and resources have already been updated on OPM’s website. You can also go directly to your insurance carrier’s website to look up plan details.
This year, there are 157 FEHB plan choices for 2024 provided by 67 carriers.
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Military personnel, Tricare open enrollment
If you’re a military service member and have questions about your Tricare health benefits, check out MilitaryTimes.com coverage here.
Molly Weisner is a staff reporter for Federal Times where she covers labor, policy and contracting pertaining to the government workforce. She made previous stops at USA Today and McClatchy as a digital producer, and worked at The New York Times as a copy editor. Molly majored in journalism at the University of North Carolina at Chapel Hill.
