ART and Insurance

Key Findings: Infertility Insurance Mandates and Use of Assisted Reproductive Technology

image of a physician talking with a couple

Fifteen states have enacted legislation requiring private insurers to cover some or all of the costs of infertility treatments. The type of coverage varies by state, with only eight states mandating reimbursement for assisted reproductive technology (ART). Because ART procedures can be expensive—especially if patients have to pay out-of-pocket for treatments—adopting an infertility insurance mandate is one way to increase access to these services. When coverage is provided, patients may be willing to transfer fewer embryos during each procedure than they would if they were paying for treatments on their own because there is less financial pressure to conceive in a single treatment cycle. This is important because transferring more than one embryo increases the risk for multiple births and can have adverse consequences for both mothers and infants. These key findings provide information on how infertility insurance mandates may affect embryo transfer practices and multiple birth rates at the individual and population-level. These findings may also be useful for policymakers, public health practitioners, and researchers.

Are there differences in the number of embryos transferred and the rates of multiple births in a state with an infertility insurance mandate versus states without a mandate?

  • In a comparison between one state (Massachusetts) with a comprehensive infertility insurance mandate, and two states (Florida and Michigan) without a comprehensive infertility insurance mandate—the study showed that ART births were more common in the state with the mandate than states without a mandate.
  • Transferring three or more embryos was more common in the states without a mandate than in the state with a mandate.
  • As a result, ART infants born in the states without a mandate were more likely to be multiples, preterm, or low birth weight compared with ART infants in the mandate state.
  • Our findings show that fewer embryos were transferred in the mandate state, resulting in lower rates of multiple births and adverse perinatal outcomes. Even so, more than 1 in 4 ART births in the state with the mandate were multiples, as the mandate helped increase access to ART use, but did not include restrictions on the number of embryos transferred during a single cycle.

Did the passage of an infertility insurance mandate create changes in ART practices over time?

  • In a different study, we compared the rates of multiple births in two states (New Jersey and Connecticut) before and after they enacted an infertility insurance mandate. The study showed that the mandates increased ART treatment use. However, while the number of embryos transferred or the rate of multiples did decrease in mandate states, these improvements were not different from improvements in non-mandate states. This suggests overall improvements in ART practices are not attributable to the mandate.
  • State insurance mandates in the states evaluated in this study exempted certain employers. This includes religious employers or those that are self-insured (i.e., the employer assumes the financial risk for providing health care benefits to its employees) and had limitations of coverage (out-of-pocket costs remaining after insurance coverage, exhaustion of insurance benefits before treatment is completed). These exemptions could explain the modest impact of the infertility insurance mandates in these states.

More about These Findings

These studies used CDC’s National ART Surveillance System, which collects data on all ART procedures performed in the United States.

More Information about ART and Multiple Births

Key Findings References

  1. Boulet SL, Crawford S, Zhang Y, Sunderam S, Cohen B, Bernson D, McKane P, Bailey MA, Jamieson DJ, Kissin DM, for the SMART Collaborative. Embryo transfer practices and perinatal outcomes by insurance mandate status. Fertili Steril. 2015;104:403-9.
  2. Crawford S, Boulet SL, Jamieson DJ, Stone C, Mullen J, Kissin DM. Assisted reproductive technology use, embryo transfer practices and birth outcomes after insurance mandates: New Jersey and Connecticut. Fertil Steril. 2016;105:347-55.