Does Medicare Cover Fertility Treatments? 

The World Health Organization (WHO) estimates that one in six adults across the globe experiences infertility, the inability to conceive after at least one year of unprotected sexual intercourse. According to the Centers for Disease Control and Prevention (CDC), infertility prevalence is about 19% in the United States, 26% if you include women unable to carry a pregnancy full term. 

Although infertility is a global issue, delivery of care and treatment is not universal. Perhaps the WHO data will serve as a foundation for developing policies and services around infertility care. In the meantime, treatment is costly, and insurance coverage varies. 

Causes of infertility 

If you are a woman having trouble becoming pregnant or carrying a pregnancy to term, discuss your concerns with a gynecologist (a doctor specializing in women’s reproductive health). Medical conditions that can lead to infertility include failure to ovulate, menstruation irregularities, endometriosis, uterine fibroids, polyps and a misshaped or scarred uterus. 

Urologists specialize in male reproductive health. Male infertility may be caused by enlarged testicular veins (varicocele), testicular injury, diabetes, autoimmune disorders, infection, cystic fibrosis and hormone disorders.  

Medicare coverage for infertility treatment

Medicare was established to provide healthcare coverage to retirees who lost group health insurance through employment. The program expanded later to include people under 65 who have a disability. Medicare provides health coverage to over 2 million adults of childbearing age.

Medicare Part B coverage is limited to medically necessary services and supplies. Your doctor may order diagnostic tests like bloodwork, urinalysis and tissue specimen testing to determine if there is a medical reason for your infertility. There is no cost to you if these tests are medically necessary. Non-laboratory diagnostic tests under Part B include MRIs, EKGs and CT scans. After you meet the Part B deductible, your cost-sharing for non-lab testing is 20% of the Medicare-approved amount. 

Medicare covers medically necessary treatment of underlying health conditions. Part A covers hospitalization, Part B covers outpatient care and office visits, and Part D covers prescription drugs.

If your doctor rules out diseases or medical issues preventing pregnancy, you may choose to visit a reproductive endocrinologist (doctor specializing in fertility) for a consultation. The fertility specialist can evaluate if you are a candidate for artificial insemination, in vitro fertilization (IVF) or other options. However, Medicare will not cover these services.

Medicaid coverage

Medicare beneficiaries with limited financial resources may qualify for Medicaid. Medicaid coverage is a national program administered by each state government, so benefits and eligibility criteria vary depending on where you live. There is no federal mandate for coverage of fertility treatments. Medicaid in New York covers ovulation-enhancing drugs for adults aged 21 through 44 experiencing infertility. Contact your state’s Medicaid agency to see if you qualify and if fertility treatments are covered.

Infertility support

Infertility can feel scary and isolating. Some people benefit from professional counseling. Medicare covers outpatient mental healthcare services to help you cope with depression and anxiety. Your out-of-pocket expense is 20% of the Medicare-approved amount after the Part B deductible is satisfied.

Organizations offering support and information include Resolve (The National Infertility Association) and the American Society for Reproductive Medicine (ASRM).

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