Last month during National Infertility Awareness Week, I saw a number of stories in the news about people dealing with the hardship of infertility. Often, a significant part of the struggle is paying for treatment. For individuals without access to coverage for infertility treatment, it can be prohibitively expensive – like so many medical procedures would be if not for insurance. While most people have no idea what hip surgery costs, because so many patients must pay out of pocket for infertility treatment the cost gets a lot of attention – which may have contributed to the historical view of this coverage as a “luxury” benefit.
But there are indications that this view is changing. Throughout the 2000s and early 2010s, Mercer’s National Survey of Employer-Sponsored Health Plans consistently found that fewer than a fourth of large employers covered in vitro fertilization (IVF), one of the most important fertility services. Over the past few years, however, we have seen notable growth in coverage for IVF and other fertility services, driven by the need to stay competitive to recruit and retain top talent; greater emphasis on inclusivity; the desire to be recognized as a family friendly employer; and stricter quality guidelines for treatment. The largest employers have been the first to act but, as trendsetters, they are likely the leading edge of a broader movement.
|Employers with 500 or more employees||Employers with 20,000 or more employees|
|Evaluation by a reproductive endocrinologist or infertility specialist||54%||58%||70%||73%|
|In vivo fertilization (intrauterine insemination)||23%||28%||34%||38%|
|In vitro fertilization||24%||27%||36%||42%|
|No coverage provided||40%||39%||23%||23%|
Source: Mercer National Survey of Employer-Sponsored Health Plans
One of the biggest barriers to employers’ adding coverage has been concern about the price tag – both the cost of the treatment itself and the perception that IVF coverage leads to high-cost claims. But these concerns are increasingly being shown to be unfounded. In Mercer’s new Survey on Fertility Benefits, the vast majority of respondents (97%) say that providing infertility coverage has not resulted in a significant increase in medical plan costs.
Fertility benefits increasingly seen as central to DEI objectives
When we talk about fertility benefits, we mean benefits offered to help build a family regardless of an employee’s gender, sexual orientation, or medical condition, or whether they are single or partnered. Services can include not only IVF treatment, but elective egg freezing (for future family planning), as well as surrogacy and adoption support and reimbursement allowances. Our survey showed two-fifths of respondents (40%) offer coverage to “support diversity, inclusion and equity (DEI) efforts.” Of note, respondents that have added coverage within the last two years are far more likely to have done so in support of DEI: 61% of respondents cited it as a primary objective, compared with 24% of respondents that have offered coverage for more than five years.
Respondents that provide coverage for IVF or IUI were asked if the benefit was specifically designed and communicated to be available to LGBTQ+ or single employees. This would mean, for example, that a clinical diagnosis of infertility based on 6 to 12 months of heterosexual intercourse would not be required for coverage. Over a third (35%) of respondents say they designed the benefit to be available to LGBTQ+ and/or single employees and made that clear in the benefit communication. And 61% of survey respondents that provide IVF coverage also offer an adoption reimbursement allowance.
Plan design is key to successful outcomes – and managing cost
While the most common barrier to providing coverage is the expense, the cost of a well-designed benefit will often be offset by the ability to achieve a successful singleton pregnancy faster with fewer complications. Most respondents (88%) place some type of limit on infertility treatment coverage, via a lifetime maximum dollar benefit (used by 60% of respondents) or a limit on the number of IVF cycles (used by 13% of respondents).
Coverage limitations based on the number of cycles rather than a flat dollar amount is considered best practice. Multiple cycles may be needed to achieve a successful pregnancy, and if the dollar amount provided will only pay for one cycle, or a portion of a cycle, there’s an incentive to cut corners by either avoiding certain screenings or transferring multiple embryos in hopes of maximizing the chance of getting pregnant. This increases the chance of multiple births, pregnancy complications, or miscarriage, which in turn raises health risks (and health care costs). Of course, when there is no coverage for IVF at all and employees wishing to become parents must pay entirely out of pocket for treatment, the financial incentive to achieve a pregnancy in just one cycle is even higher.
Some employers rely on specialty vendors to assist with fertility benefits; examples include ARC Fertility, Carrot, Kindbody, Progyny, and WIN Fertility. These vendors tend to have more flexibility in the administration of the benefit compared to traditional medical carriers, and bring enhanced coaching and care navigation, higher-quality resources, and ultimately improved outcomes. Virtual care models, like Maven, are another option. Among all survey respondents that provide fertility benefits, 12% use a specialty vendor; this rises to 21% of respondents with 5,000 or more employees.
Fertility coverage deserves attention more than just one week a year
Other forces are adding momentum to this movement. In 2017, the American Medical Association recognized infertility as a disease, and there is increasing activity by state and federal governments to improve access to infertility treatment. Nineteen states have fertility insurance coverage laws, and 13 of those states mandate IVF coverage in fully insured plan offerings. And as this momentum continues to build, along with the brighter spotlight on DEI, we can count on employees’ voices to get louder. The requests will start coming, if they haven’t already. This year’s National Infertility Awareness Week may have just passed, but for employers that don’t provide a comprehensive fertility benefit, now might be the right time to give it some consideration.
The Survey on Fertility Benefits 2021 was conducted in February, 2021. Overall, 459 employers responded: 254 respondents provide some level of infertility coverage and 205 respondents do not provide any coverage. The survey was commissioned by RESOLVE: The National Infertility Association.