Is IVF Covered by Insurance in Maryland?

In Vitro Fertilization (IVF) offers a path to parenthood, but its cost can be substantial, often $11,000 to $17,000 or more per cycle, plus thousands for medications. Understanding insurance coverage is crucial to manage these expenses.

Maryland’s Fertility Mandate

Maryland has legislation requiring certain insurance plans to cover fertility treatments, including IVF. This mandate applies to insurers, nonprofit health service plans, and Health Maintenance Organizations (HMOs) that issue or deliver health insurance policies within the state and provide pregnancy-related benefits. This law prevents these entities from excluding coverage for outpatient IVF expenses. Benefits are generally provided to the same extent as those for other pregnancy-related procedures or, for HMOs, other infertility services.

This state mandate primarily applies to fully-insured plans, which are regulated at the state level. Self-funded plans, often used by larger employers, are exempt from state insurance mandates under federal law. Additionally, the mandate generally does not apply to health insurance policies issued or delivered to small employers with 50 or fewer employees. As of January 1, 2021, Maryland removed the requirement for patients to be married to receive IVF benefits under the mandate, broadening access to a wider range of individuals seeking fertility care.

Eligibility and Coverage Criteria

To qualify for coverage under Maryland’s mandate, individuals must meet specific eligibility conditions. The law defines “infertility” as the inability to conceive or sustain a successful pregnancy over a certain period, or a diagnosed medical condition. For opposite-sex couples, this typically means a history of at least one year of unprotected intercourse failing to result in pregnancy, a reduction from the previous two-year requirement.

For same-sex couples or unmarried individuals, infertility can be demonstrated by three attempts of artificial insemination over the course of one year that have not resulted in pregnancy. Alternatively, eligibility can be established if infertility is associated with specific medical conditions, regardless of the duration of attempts to conceive. These conditions include endometriosis, exposure to diethylstilbestrol (DES), blockage or surgical removal of one or both fallopian tubes, or abnormal male factors such as oligospermia.

A common prerequisite for coverage is that the patient must have been unable to achieve a successful pregnancy through less costly infertility treatments for which coverage is available under their policy. This often means trying less intensive interventions, such as ovulation induction or intrauterine insemination (IUI), before IVF coverage becomes accessible. Furthermore, all IVF procedures must be performed at medical facilities that adhere to applicable guidelines or minimum standards set by professional organizations like the American College of Obstetricians and Gynecologists or the American Society for Reproductive Medicine.

Covered Services and Limitations

Maryland’s mandate requires coverage for outpatient expenses related to IVF procedures. Covered components typically include diagnostic testing to identify the cause of infertility, necessary fertility medications, the egg retrieval procedure, laboratory fertilization of eggs, and the subsequent embryo transfer into the uterus. Coverage may also extend to the cryopreservation of embryos for future use.

The mandate allows for certain limitations. Insurance plans may limit coverage to three IVF attempts per live birth, meaning that once a live birth occurs, the cycle count may reset for subsequent attempts. There is also a potential maximum lifetime benefit of $100,000 for IVF procedures under the mandate. The law explicitly states that insurers are not responsible for costs incurred in obtaining donor sperm.

Beyond IVF, Maryland law also mandates coverage for standard fertility preservation procedures when medically necessary due to treatments that may cause iatrogenic infertility, such as chemotherapy. This separate but related provision aims to protect the fertility of individuals facing medical interventions. Even with mandated coverage, patients will incur out-of-pocket costs such as deductibles, co-pays, and co-insurance.

Accessing and Utilizing Your Benefits

To utilize your benefits, begin by contacting your insurance provider or reviewing your Summary of Benefits and Coverage (SBC) document. This will clarify what is covered, any specific limitations, and your financial responsibilities, such as deductibles, co-pays, and co-insurance amounts.

Many IVF treatments require pre-authorization from your insurance company before procedures begin. This process can take up to a month for approvals. Your fertility clinic’s financial counselors often assist with this step, helping to navigate the paperwork and communication with your insurer. Finding an in-network fertility specialist and clinic can significantly reduce your out-of-pocket costs, as these providers have negotiated rates with your insurance plan.

Despite coverage, you will still be responsible for your plan’s deductible and any applicable co-pays or co-insurance, which can be substantial for IVF. For instance, coinsurance for outpatient services might be around 50% after your deductible is satisfied. Carefully track all out-of-pocket expenses, as these contribute towards your annual out-of-pocket maximum, after which your plan typically covers 100% of approved costs. If a claim is denied, you have the right to appeal the decision through your health plan’s internal grievance process, and if still unsatisfied, you can appeal to the Maryland Insurance Administration, with assistance available from the Maryland Attorney General’s Health Education and Advocacy Unit.