Fertility issues continue to grow throughout the United States. Their frequent representation in the media has drawn the attention of many lawmakers. Recently, a New York State Department of Financial Services feasibility study looked into mandating coverage for fertility preservation (FP) and in vitro fertilization (IVF) services where it is deemed medically necessary.
The feasibility study also examined coverage as well as laws that exist in other states. The Department of Financial Services also procured an actuarial vendor to conduct the financial analysis. This also included a projection on the potential impact on premiums for providing such coverage.
Based on the information collected and analyzed the State of New York can effectively implement a requirement for medically necessary Fertility Preservation coverage for patients with cancer or those who undergo treatment for a medical condition that has the potential to affect their fertility.
The analysis estimates that mandating the provision could affect premiums for coverage by approximately .02%. This is considered a relatively small cost to provide coverage that has benefits to individuals who suffer from significant medical conditions including cancer.
The feasibility study also looked into IVF treatment coverage. With these treatments, the premium impact would be somewhat higher. It was estimated to increase premiums by .5% to 1.1%.
Current Fertility Preservation And In Vitro Fertilization Coverage Requirements
Under current New York State law, medical coverage requires surgical, treatment, and diagnostic services for the patients where infertility is the result of malformation, a disease, or some type of physical dysfunction. The coverage levels include basic infertility services that may be needed to accurately diagnose as well as treat infertility. This includes an initial evaluation, laboratory tests, and other diagnostics.
At the same time coverage is also required for more comprehensive infertility services. This includes ovulation induction as well as professional monitoring, and artificial insemination. However, medically-necessary Fertility Preservation is not specifically addressed under current New York state laws. It’s also worth bearing in mind that IVF treatments are specifically excluded from the mandated coverage law, provided by employers.
The New York Department of Financial Services further reminds insurers that the American Society for Reproductive Medicine notes that infertility cannot distinguish between heterosexual individuals in a relationship or those who are married, it includes individuals who are in a same-sex relationship, who are single individuals or based on their gender identity. Therefore, insurers must provide coverage for infertility treatment to an individual who meets these criteria.
What Would The Improved Coverage Entail?
When it comes to Fertility Preservation the level of coverage can vary depending on the type of treatment. Some of these procedures may or may not already be covered in relation to other medical conditions.
Under the proposed mandate decisions would be based on informed medical advice. The patient will be encouraged to make decisions based related to their doctor’s medical advice rather than directly influenced by any limiting financial concerns.
When it comes to the IVF component of the proposed mandate consideration will be given to limiting the number of cycles that a patient or couple can receive. It also ensures that coverage will not be discriminatory or limited to group size.
IVF cycle coverage can, however, be limited. Yet the Affordable Care Act does not permit a dollar limit to the individual or in a small group market. For example, a three-cycle limit would roughly equate to a $50,000-lifetime limit which is currently enacted in the New York State Empire Plan.
Under the proposed mandate the State might consider placing a limit on the number of egg retrieval attempts that can be made for an individual patient.
It’s worth noting that an IVF cycle is defined within the statute. Under an insurer’s current policy, a cycle may be defined as all treatment modes.
In some cases, IVF coverage might be viable for review based on the patient’s medical needs as well as established age limits between 21 to 44 years of age. It would also grant the patient the right to pursue an external appeal under Article 49 of the Insurance Law and Public Health Law.
Regarding prohibiting procedural hurdles, other states require the exhaustion of other assisted reproductive technology and procedures before IVF coverage can be approved. It’s worth noting that each type has its own risks and potential benefits. This means that the proposed mandate should not include limitations. However, it should permit a medical necessity review before approving treatment.
Other Factors That Could Influence Treatment Approval
The proposed mandate would also recognize other factors that could influence the approval of possible fertility treatments.
Decreased instances of miscarriage may be a factor in some cases. Potential coverage may require certain types of genetic testing to screen for genetic issues which could lead to repetitive miscarriage problems.
This could include genetic conditions that impact things like pre-implantation as well as genetic diagnosis for aneuploidy testing in identifying mosaic embryos.
Decreased productivity levels could also be a benefit in reducing time where the patient is out of the office, on short-term disability, or long-term disability.
A study performed in Scandinavia in 2006 noted that women receiving a single embryo transfer as part of the IVF process had an average of nine fewer sick days in that year. This was compared to women who received a double embryo transfer. It was found that the average cost difference between these two groups was roughly $850 less per patient.
Decreased depression issues with infertile couples can also be a beneficial factor. Several studies have noted that depression is a common side effect for one or both members of a couple with fertility issues. One statistic notes that the prevalence of major depression in infertile couples can range from as little as 15% all the way up to a staggering 54%!
These mental health issues could also include anger management issues, chronic depression, anxiety, marital instability, and sexual dysfunction, as well as social isolation. A study published in the Journal of Clinical Psychology estimated that the economic burden of depression can be as high $210.5 billion per year, which includes decreased productivity in the workplace.