How will the Affordable Care Act (ACA) affect infertility benefits?

If you’re an infertility patient in New Jersey and wondering how the Affordable Care Act (ACA) better known as “Obamacare” will affect your current infertility benefits or access to future infertility care, you’re not alone. With the affirmation of the ACA in 2010 and launch of the new public insurance exchanges on October 1, 2013 inquiries to us here at Reproductive Medicine Associates of New Jersey (RMANJ) have understandably increased – and with a greater sense of urgency.

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Infertility benefits vary greatly from employer to employer. If you currently have benefits for infertility treatment either mandated by your state or offered by your employer, you should speak with your benefits administrator and insurance company soon.  For many January 1, 2014 will likely mean a new configuration of health benefits for a number of conditions including infertility. Here’s a few of the most common questions that we’ve been asked so far by current and prospective patients.

Q. What are the 10 EHB’s covered under the Affordable Care Act and is infertility part of them?

The ACA provides for 10 essential health benefits (EHB’s) and service categories that must be covered by certain plans, starting in 2014. They are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

You’ll notice that infertility or reproductive medicine is not specifically listed on the list of EHB’s. While it could fall under items 1 or 4 it’s just too soon to understand and too easy to speculate one way or the other.

Q. My employer currently follows the NJ Family Build Act insurance mandate and I have benefits for infertility services. Will I still have these mandated benefits on January 1, 2014?

obamacare-factThe short answer is we just don’t know yet. However,  according to National Conference of State Legislatures website, ‘‘the ACA does not directly alter or preempt state mandates; however, starting 2014, if states elect to include certain services in qualified health plans to exchange enrollees not included in the ‘essential health benefits,’ the state will have to pick up the cost.’’[1]

If the state eventually does maintain the current infertility care mandate, they’re going to want to maximize the cost of care –which is a good thing.

IVF programs that are practicing a new treatment paradigm of extended embryo culture, aneuploidy screening, blastocyst stage biopsy, endometrial synchrony, and single embryo transfer will make it easier for the state to continue providing infertility benefits. It’s better and safer care that has shown to provide excellent chance for success over fewer cycles and with fewer multiple deliveries from IVF.

Before the NJ mandate was passed in 2001 some companies provided some level of infertility benefits. Many employers understand that providing health benefits including infertility coverage is a good employee retention strategy. With so many Fortune 500 companies headquartered in New Jersey we hope many employers will still continue to provide infertility benefits in 2014.

Q. I used funds from my flexible spending account (FSA) to help pay some of my out of pocket costs for infertility care; will that change with the ACA?

Contributions to flexible spending accounts (FSA) have been reduced to a maximum of $2,500 under the ACA.  At the same time, changes in tax codes with the ACA will likely reduce the amount of deductions patients could take for infertility treatment in the future. And if your adjusted gross income is over $200,000, you’re excluded from taking any deductions or so it would appear.

Patients should not only talk to their physician about their infertility but it would be a good idea to talk to their HR department about any benefits and FSA’s. They should also investigate the deduction changes under the ACA with a qualified accountant.

Q. I’m enrolling into a new private exchange will I have access to infertility coverage?

Again we can only speculate but with the healthcare plans ranging from bronze, silver, gold, and platinum we’d expect that at least some of the plans would offer infertility services. It’s likely that with the higher the level of benefit infertility coverage would be offered.

If you’re under 35 and have been trying to get pregnant for 12 months without success it might be a good time to speak with a reproductive endocrinologist. At the same time if you’re shopping in the newly opened exchanges for a plan you might want to investigate levels and costs of infertility coverage.

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