When states require fully insured employers to cover in vitro fertilization (IVF), what do self-insured employers provide?

TL;DR

Many self-insured employers in states requiring IVF coverage still don't offer it, and those that do often have strict limits.

Contribution

This study reveals the limited impact of state IVF mandates on self-insured employer coverage and highlights the importance of coverage details.

Findings

Only 41% of self-insured employers in mandate states cover IVF.

Most IVF coverage plans impose lifetime limits, either in dollars or cycles.

Coverage comprehensiveness varies by industry and employer type.

Abstract

Sixty-five percent of US workers get their health insurance from self-insured employers who are exempt from state insurance coverage mandates. We evaluated if self-insured employers in states with in vitro fertilization coverage mandates offer insurance coverage for in vitro fertilization and other fertility treatments, and if so, we evaluated the details of that coverage.

We qualitatively analyzed 165 health plan documents from 2019 to 2021 from 45 self-insured employers in seven states with in vitro fertilization coverage mandates (Arkansas, Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York).

A minority (41%) of self-insured employers in states with in vitro fertilization coverage mandates cover in vitro fertilization. Most health plans impose lifetime limits on in vitro fertilization use, with those limits split almost evenly between dollar-based and cycle-based limits. Finally, health plans in our sample from the finance and insurance, manufacturing, and educational services industries, and from non-union employers, had more comprehensive coverage for infertility testing and treatments.

While state in vitro fertilization coverage mandates are important policy initiatives to improve access to in vitro fertilization, our findings suggest that state mandates are insufficient to expand access to all patients since a minority of self-insured employers in our sample covered in vitro fertilization. In addition, it is insufficient to label a health plan as simply “covering” or “not covering” in vitro fertilization; instead, the details of that coverage matter since the “coverage” may not be sufficient for the patient to afford even one in vitro fertilization attempt.