How can Affordable Care Act Impact Access to Infertility Treatment?

by Davina Fankhauser
President - Fertility Within Reach

The United States Supreme Court ruled that the Affordable Care Act is constitutional.  So what does that mean for Infertility health care?  We’ll tell you, but first some basic information to catch everyone up.

The Affordable Care Act directed the Secretary of Health and Human Services (HHS) to define essential health benefits (EHB).

The EHB include items and services within the following 10 benefit categories:

(1) Ambulatory patient services

(2) Emergency services

(3) Hospitalization

(4) Maternity and newborn care

(5) Mental health and substance use disorder services, including behavioral health treatment

(6) Prescription drugs

(7) Rehabilitative and habilitative services and devices

(8) Laboratory services

(9) Preventive and wellness services and chronic disease management

(10) Pediatric services, including oral and vision care.


Each state will select an insurance plan, containing these 10 benefit categories, to be their state’s “Benchmark plan”.  The state benchmark plan is the minimum coverage offered by insurers.

Who must abide by the benchmark plan?
(1) Non-grandfathered health plans in the individual and small group markets
(2) Medicaid benchmark and benchmark-equivalent
(3) Basic Health Programs must cover the EHB
Insurers are still able to offer more than what is covered in the benchmark plan.

Who is exempt:
Self-insured group health plans, health insurance coverage offered in the large group market, and grandfathered health plans are not required to cover the essential health benefits.  So check and see if you employer is self-insured.  Also, just because an employer is NOT required to cover the essential health benefits, doesn’t mean they won’t.  So make sure you review your health care policy carefully.

States with legislated Infertility mandated benefits:
1. If Infertility treatment is included within your state’s benchmark plan; it will not matter if your state chose to eliminate the legislated mandate.

2.  You want to ask your insurance department to select a benchmark plan that offers Infertility health coverage is included in the benchmark plan.

The timeline:
States will select their benchmark plans by September 2012.
The plans will go into effect beginning in 2014.

What does this mean for Infertility treatment?
(1)  Patients with reproductive health conditions should not be denied health coverage due to pre-existing conditions.

(2)  There is still a chance for you to have coverage for fertility treatment in your state.

Impossible?  Only if you don’t try.  Unlikely?  Tell that to those in states who have recently celebrated legislative success related to women’s reproductive rights.

Contact your State’s Division/Department of Insurance and ask them to select a benchmark plan which includes some form of Infertility health coverage.

We want to ensure patients can be diagnosed in a timely manner.  Early treatment of this disease is most effective and optimizes the chances of a healthy outcome for patients and their future children.  To demonstrate the cost effectiveness of such coverage, you can provide supportive facts to substantiate your request.

For additional information and support, please contact us.  Together, we can make a difference.




Trackback from your site.

Davina Fankhauser

President - Fertility Within Reach