An embryologist uses a microscope to examine an embryo, visible on a monitor, at a clinic in New York. Efforts to extend fertility-related health care to Medicaid patients have failed over cost concerns. Richard Drew/The Associated Press
As more states require private insurers to cover fertility-related health care, many efforts to extend similar protections to Medicaid patients this year have foundered over cost concerns.
Only two states provide significant fertility coverage through Medicaid: New York, which offers fertility medications, and Illinois, where Medicaid will cover the storage of sperm or eggs for those facing a medical treatment that will likely render them sterile, such as for cancer. Both states modified their Medicaid plans to include the new services in 2019.
Twenty-one states already require private insurers to cover fertility treatments, and more are considering it as fertility rates drop and more women postpone childbirth into their 30s and 40s. But some legislators have noted that such laws leave out women with low incomes who receive health care coverage through Medicaid, a joint federal-state program that covered nearly 20 million women in their reproductive years in 2019.
A Connecticut bill to add in vitro fertilization, known as IVF, to the state’s private insurance mandate and to include it and other fertility treatments in the state’s Medicaid program failed to pass this year.
In 2020, Utah requested a waiver from the federal government to provide IVF and genetic testing for Medicaid recipients with cystic fibrosis, spinal muscular atrophy, sickle cell anemia and several other conditions. In 2021, the state added a request to expand Medicaid coverage to include fertility preservation for people diagnosed with cancer. Negotiations between the state and federal officials are ongoing.
Expansion of fertility coverage into Medicaid has been, politically speaking, a non-starter.
– Dr. Christopher Herndon, medical director of the Division of Reproductive Endocrinology & Infertility at the University of Washington
District of Columbia legislators also proposed adding in vitro fertilization coverage to Medicaid and other low-income insurance as part of broader legislation requiring that private insurers cover IVF. But because of cost concerns, they dropped the Medicaid portion of the measure from the final law enacted this year and set to take effect in October.
“At this point, if states cover fertility treatments from Medicaid recipients, states must cover 100% of the cost,” said D.C. Councilmember Christina Henderson. “This makes it nearly impossible for any state to provide that expanded coverage.” The new law directs District health officials to negotiate for cost-sharing in the future, she said.
Similarly, a Washington state bill that would have included in vitro fertilization coverage for some state employees on Medicaid survived two committee votes but failed to reach a final vote. State Rep. Monica Stonier, a Democrat who sponsored the bill, said she heard some supporters wanted to wait for a state cost study that didn’t come out until this week.
“They’re waiting for another piece of information,” Stonier said. “I don’t think that was necessarily a good reason to stall. We could have made adjustments as we needed to. The sooner we can do this, the sooner employees can start making financial plans for this.”
The report estimated the cost of adding in vitro fertilization and fertility preservation for everyone in Washington’s Medicaid program to be $22.6 million for 2024.
“Unfortunately, expansion of fertility coverage into Medicaid has been, politically speaking, a non-starter in most states,” said Dr. Christopher Herndon, medical director of the Division of Reproductive Endocrinology & Infertility at the University of Washington.
The federal Centers for Medicare & Medicaid Services, known as CMS, which signs off on state Medicaid changes, does not require states to cover infertility under Medicaid but allows them to do so, said spokesperson Julie Brookhart in an emailed statement. “States may elect to cover such services and determine the types of covered treatments,” Brookhart wrote.
Some states do cover some diagnosis costs for infertility under Medicaid, according to a KFF report: Georgia, Hawaii, Massachusetts, Minnesota, New Hampshire, New Mexico and New York.
Medicaid coverage is critical to make infertility treatment available equitably, especially to Black families, according to a study published last year in the American Journal of Obstetrics & Gynecology. State mandates for private insurance alone don’t help with racial disparities when it comes to in vitro fertilization, and may make them worse, according to the study.
Data from Massachusetts, one of the states in the study, showed that “Insurance mandates [for private insurers] increased the total utilization of fertility care, but predominantly among those who were already most likely to access it, specifically, White, educated, wealthy women.”
A co-author of the study, Katherine Kraschel, an assistant professor of law and health sciences at Northeastern University, said she helped draft Connecticut’s bill, which two committees approved but which did not reach a floor vote, even after a legislator proposed dropping the Medicaid provision until the state could evaluate it.
Henderson, the District of Columbia council member, said in a hearing she hopes to expand access to fertility treatment in the District for both Medicaid and DC Health Care Alliance, a health insurance program for low-income residents who don’t qualify for Medicaid.
The District will negotiate with federal officials, Henderson said. Meanwhile, the D.C. law will only require private insurers to cover in vitro fertilization and fertility preservation, while Medicaid will only cover fertility diagnosis and medication, similar to New York state’s Medicaid program.
“This change matches the most extensive Medicaid coverage in the country,” Henderson said. “The [health] committee did hope to expand Medicaid and DC Alliance coverage to include the full spectrum of care including IVF and fertility preservation services. However, as no state has ever done this, there were concerns that CMS [Medicaid] would not consider such services medically reasonable and necessary.”
Also, Henderson said in the hearing, many fertility specialists are not enrolled as Medicaid providers. The District needs to reach out to them to ask them to do so, she said, “to ensure that not just coverage but real access to fertility services are available to all District residents.”
Kraschel, the Northeastern University assistant professor, said states may be reluctant to be the first to try something but noted that New York and Illinois have shown that Medicaid coverage for fertility is possible, at least in a limited way.
“I would hope this moment emboldens state legislatures to do everything they can to secure reproductive freedom for all their constituents, that states would be proud to be the first to provide comprehensive fertility coverage through Medicaid,” she said. “That’s just not happening so far.”
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