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States are increasingly adopting health insurance mandates requiring coverage of everything from mental health treatment to contraception. But they've been more hesitant to require infertility coverage — a condition that affects about 7.3 million Americans, or about one in eight couples, according to Resolve, a nonprofit infertility-patient advocacy and information organization.

Insurance companies argue that if they are hit by yet another coverage mandate, they will be forced to raise premiums. Insurers say that will prevent even more Americans from obtaining affordable health insurance. And infertility coverage is one of the more expensive mandates around. According to the Council for Affordable Health Insurance (CAHI), adding a mandate to cover in vitro fertilization adds 3 to 5 percent to the cost of group health insurance policies.

See State infertility-treatment insurance laws.

Religious groups that oppose mandating infertility coverage, particularly the Catholic Church, contend some infertility services are tantamount to abortion because some treatments lead to the destruction of human embryos. The Catholic Church also opposes fertilization outside the body on religious grounds.

Businesses, especially small employers, say mandating infertility coverage drives up health insurance costs. Some businesses say that would force them to reduce benefits or eliminate health coverage.

Couples facing the emotional devastation of an empty crib say they just want the same health care rights as those afforded to people with such conditions as diabetes, mental illness or cancer.

"Infertility is a disease and it ought to be treated as any other disease," says Sean Tipton, public affairs director for the American Society of Reproductive Medicine (ASRM) in Birmingham, Ala. "That means it ought to have insurance coverage, it ought to have funds for research, and people ought to be able to access the treatment."

How to find coverage

"It's just really hard to find anything," says Tipton. "The economic reality is that if there are customers demanding coverage, then they're going to provide it. But the insurance company customers are employers, and they're not demanding it. The other thing is that no insurance company wants to be the only company covering infertility."

For patients seeking infertility treatment insurance, coverage is elusive. Here are some suggestions from advocacy groups on becoming your own advocate:

• Understand your state law. Many states currently have some sort of infertility legislation on the books. They range from extensive mandates like those in Massachusetts that require any insurance plan to cover even the most advanced infertility treatments, to Texas law, which requires only that insurers make such coverage available should employers wish to purchase it. Despite the fact no federal law requires insurance coverage for infertility treatment, 15 states have enacted some type of infertility insurance coverage law. Each law is different, but most can be generally described as either a mandate to cover or a mandate to offer.

  Additionally, the laws can have many loopholes and may exclude certain types of insurers and employers. Some laws, for instance, exclude HMOs, and most exclude self-insured companies. They also might exclude certain infertility treatments or impose time limits on treatment.

• Negotiate with your employer. Just because your employer doesn't currently offer infertility coverage now doesn't mean you can't change their mind. Self-funded plans can voluntarily add coverage, and other companies can switch to health plans with infertility benefits. Resolve has a sample letter you can send to your employer requesting such benefits.

• Read your health insurance policy. It is vital to understand your plan. That means reading not just the summary that your employer hands you, but also the actual policy — which you can get from your employer. Request a copy in writing. If the person at work who is responsible for giving you your policy fails to do so within 30 days, he or she can be fined under federal law.

  Remember, too, that vague policies work in favor of the consumer. If the insurance company is going to deny any benefits, the exclusions must be clearly stated in the contract. If there is no exclusion listed, you can't be denied treatment, whether that's for infertility or another illness.

• Get it in writing. Some people undergo costly infertility treatments only to be denied reimbursement later by the insurance company. A letter from the insurance company known as a "predetermination of benefits" says exactly what will be paid for — and it's legally binding. Make sure you get one.

• Fight back. If your insurance company won't reimburse you for treatment or won't authorize treatment, you can appeal the decision. Insurance companies have internal appeals processes that allow you to request that a decision be reversed. (And some states are mandating independent external review boards.) Contact the insurance company and ask it to provide detailed reasons for the denial.
  
  

  Some reasons insurers give for denying claims: infertility is not an illness; treatment is not medically necessary; or the treatment is experimental. Your doctor can help you document for your insurance company why the treatment is medically necessary and not experimental, Resolve says.

Advocates urge a grassroots movement

Consumer advocacy groups recognize the need to control costs in infertility, too. Neither Resolve nor ASRM are pushing carte blanche infertility benefits; both recognize the need for some limits on the number of attempts people are allowed to try to get pregnant, particularly since multiple attempts of some treatments can actually reduce the success rate.

But the only way insurance coverage is going to expand — or if there is ever going to be a federal mandate, they say — is with the help of a grassroots movement among those seeking infertility treatment. "Complain loudly and long to your employers and elected representatives," Tipton advises. "Work with the benefits people at your job to find out if they cover this, and if not, urge them to change health plans. If Congress wants to, it can pass a law that tells insurance companies they will cover this. This is the ultimate family issue."

The case of Aetna: What happens when you have something everyone wants?

Aetna U.S. Healthcare was a pioneer among insurance companies, choosing to offer expensive infertility coverage in a basic benefits package sold to employers.

In January 1995, Aetna says it became the only U.S. insurer to offer advanced reproductive technology (ART) in its basic HMO and POS plans. Thus, any employer that purchased Aetna's basic plan was able to automatically secure coverage for such high-tech infertility treatments as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) — treatments that cost upward of $10,000 for each attempt.

The honeymoon lasted three years. Aetna got more than it bargained for. Countless couples desperate for coverage apparently persuaded their employers to purchase Aetna's basic plan — offered only as a group health benefit, not as an individual policy — so that they could take advantage of the costly infertility treatments. And they did, en masse. And so in April 1998, Aetna dropped ART coverage from its basic plan (except in states that mandate such coverage for all insurance plans).

Today, the company won't come right out and say it was "swamped," but it does concede that people chose the plan solely for the infertility benefits. "Obviously, we were hoping other insurers would be offering this benefit, and that never happened," says Aetna spokesperson Betsy Sell. "People would join the plan just to access that particular benefit."

How did Aetna know that? "When somebody joins the plan and leaves right after using the infertility services," Sell explains. "One of the things managed care companies stress is getting members in for the long term. When someone leaves after a year or so, the preventive and wellness programs we have in place don't have the full effect for them."

Cost was an issue, too, of course, although Aetna is reluctant to admit its decision to yank ART coverage from the basic plan had anything to do with expense, and it won't release any figures. "It is a benefit that is certainly more expensive," Sell says.

Aetna took it on the chin when it dropped ART. Resolve and ASRM publicly blasted the company, calling it irresponsible and contending its decision was as arbitrary as deciding to cover a patient's broken right leg but not a broken left leg.

Just a week after Aetna announced it was dropping ART services from its basic plan, the company said it would still provide coverage of ART through a rider that employers could purchase for extra money. At the time, company president Michael J. Cardillo said decisions about which benefits to purchase should be made by the employers who must fund them, not the insurance companies. Aetna's basic group health plan still provides coverage for some infertility treatments, such as surgery, medications and artificial insemination.

While unhappy with Aetna's ART decision and the lack of widespread insurance coverage for infertility, ASRM spokesperson Sean Tipton says the finger of blame must also be pointed at employers. "Coverage isn't driven by insurers nearly as much as it's driven by employers," he says. "If employers want infertility coverage in their health plans, they'll get it."

Other insurers offer group infertility coverage

CIGNA, too, offers infertility coverage as a rider that employers can buy only in addition to a regular health insurance plan. The cost of the rider depends on the particular contract with each employer. Employers set the co-pay cost and can establish limits on how many trials of certain procedures will be offered.

Additional insurers that offer ART and other infertility coverage include Blue Cross Blue Shield and UnitedHealthcare, according to the International Council on Infertility Information Dissemination Inc., a family-building non-profit organization. See its List of Infertility and Adoption-friendly Employers for more information.

Every little bit helps

In November 2008, CVS Caremark launched a "Fertility Care Program" offering drug discounts to infertility patients.

"The Fertility Managed Plan is available through CVS Caremark Specialty Pharmacy only. The program is designed to offer discounts on fertility medications and is intended for those who do not have this type of coverage, or have exhausted their benefit for fertility medications," says Christine Cramer, spokesperson for CVS Caremark.

The program offers patients a 30 percent discount on fertility medications after a $10 enrollment fee. More information can be found at CVS Caremark.