How State-Mandated IVF Insurance Influence Accessibility & Equity?

Authored by: Vivian Xu

Art by: Grace Liu

Reproductive technologies, especially in vitro fertilization (IVF), are important to the aspiration of motherhood for millions of Americans. However, insurance coverage and access for fertility care in the U.S., particularly for reproductive services, has great disparities and varies by state, income, and race.

Health insurance for IVF is key to reproductive freedom. Individuals and couples that experience infertility or require reproductive help utilize in vitro fertilization (IVF), an assisted reproductive technology (ART). Factors such as age, certain health conditions, and social situations, including same-sex couples or single parents, can lead individuals to seek fertility treatment.In vitro fertilization (IVF) offers a possible path to pregnancy, but many people cannot access it due to its high cost; on average between $15,000 and $30,000 per cycle. A cycle refers to one full round of treatment, beginning with ovarian stimulation and egg retrieval, followed by fertilization in the lab and embryo transfer into the uterus. Because success rates per cycle are relatively low, patients often need multiple rounds; on average, about six cycles, to achieve a successful pregnancy. Therefore, treatment is only practically accessible to either those who can afford the price or who reside in one of the few states that offers insurance for it [1].

13.4% of American women between the ages of 15 and 49 are affected by infertility, yet not all of them have equal access to care [2]. Discrepancies are especially evident when it comes to race: even when their medical needs are identical, Black and Hispanic women seek infertility care at a rate that is almost half that of white women [3]. One significant factor is financial problems; households with incomes over $100,000 seek IVF twice as frequently as those with incomes under $25,000 [4].

Other factors that contribute to inequality in IVF access include cultural stereotypes, a lack of insurance, and the concentration of fertility clinics in less affluent, rural neighborhoods. In the US, only 8.63% of fertility clinics are found in counties with a majority of Black or Hispanic people [5].

Legislation requiring some form of infertility coverage is now in place in 19 states. However, benefits vary greatly: at the low end, some states provide only limited benefits, including infertility diagnostic testing or narrowly scoped medication coverage; while at the high end, Massachusetts and Illinois cover multiple IVF cycles and fertility preservation with minimal restrictions [6]. States with insurance mandates witnessed a 132% increase in IVF utilization compared to states without such legislation [7]. Mandated coverage also reduces racial disparities: racial disparities in IVF use were 25-39% lower in states with long-standing mandates than in those without coverage [8].

Unfortunately, even in cases when mandates are in place, access is not fully equal. For instance, the majority of mandates only apply to fully insured employer plans, but 61% of U.S. workers are covered by self-funded plans [9]. Millions of people, especially those who work for big firms, because typically these firms operate under self-funded health plans governed by the federal Employee Retirement Income Security Act (ERISA). These plans are exempt from state insurance mandates which means that even if a state requires insurers to cover IVF, self-funded employer plans can legally opt out.

Furthermore, additional laws may impose limitations on eligibility. New York’s 2020 IVF Insurance Mandate law restricts coverage to persons using their own embryos and only applies to large-group plans with 100 or more employees, thereby excluding same-sex couples or patients who use donor materials [10]. Laws like these sustain inequities toward low-income workers and LGBTQ+ families. 

Despite these shortcomings, evidence shows that state mandates significantly expand access across income and racial groups. Massachusetts, one of the earliest adopters of comprehensive IVF coverage, reports one of the highest IVF utilization rates per capita in the US and one of the lowest racial gaps in treatment outcomes [11].

The unfairness of the US system can be seen by comparing to foreign countries. In Denmark, they offer free treatment in public clinics for up to three cycles for a first child, and recently expanded to a second child for those referred before the age of 40. In the US, the national standard recommends up to three NHS funded cycles for most women under 40. By construct, the US access depends on a patchwork of state mandates and employer discretion. 

Recent policy developments show a slow but notable improvement toward treating infertility as a medical condition instead of an elective procedure. A2025 federal executive order on infertility directed federal agencies (HHS) to research coverage expansions while the Family Building FEHB Fairness Act required IVF coverage for federal employees. Some states also started taking action. California’s Senate Bill 729 will mandate IVF coverage for large group plans starting in 2026, and Virginia and Tennessee passed new laws both expanding coverage and protecting IVF access [12]. These changes have the potential to set important precedents, showing that inclusive, reasonably priced, and well-regulated coverage can reduce reproductive disparities in policy design.

References

1. CNY Fertility. (2025, May 9). Everything You Need to Know about Discounted IVF. CNY Fertility. https://www.cnyfertility.com/discounted-ivf/

2. CDC. (2024, December 10). National ART Summary. Assisted Reproductive Technology (ART). https://www.cdc.gov/art/php/national-summary/index.html

3. Deepa Dongarwar, Mercado-Evans, V., Adu-Gyamfi, S., Laracuente, M., & Salihu, H. M. (2022). Racial/ethnic disparities in infertility treatment utilization in the US, 2011–2019. Systems Biology in Reproductive Medicine, 68(3), 180–189. https://doi.org/10.1080/19396368.2022.2038718

4. Galic, I., Negris, O., Warren, C., Brown, D., Bozen, A., & Jain, T. (2021). Disparities in access to fertility care: who’s in and who’s out. F&S Reports, 2(1), 109–117. https://doi.org/10.1016/j.xfre.2020.11.001

5. Tierney, K. I. (2022). Geographic distribution of assisted reproductive technology clinics in the USA: a multilevel sociodemographic analysis. Journal of Assisted Reproduction and Genetics. https://doi.org/10.1007/s10815-022-02607-9

6. Insurance Coverage by State | RESOLVE: The National Infertility Association. (2021, August 27). RESOLVE: The National Infertility Association |. https://resolve.org/learn/financial-resources/insurance-coverage/insurance-coverage-by-state/

7. Peipert, B. J., Chung, E. H., Harris, B. S., & Jain, T. (2022). Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States. American Journal of Obstetrics and Gynecology. https://doi.org/10.1016/j.ajog.2022.03.003

8. Liao, C., Kotlyar, A. M., & Seifer, D. B. (2023). Effect of State Insurance Mandates on Racial/Ethnic Disparities in Utilization and Outcomes of Donor Oocyte Assisted Reproductive Technologies. https://doi.org/10.1016/j.fertnstert.2023.02.037

9. Insurance Coverage by State | RESOLVE: The National Infertility Association. (2021, August 27). RESOLVE: The National Infertility Association |. https://resolve.org/learn/financial-resources/insurance-coverage/insurance-coverage-by-state/

10. Imrie, R., Ghosh, S., Narvekar, N., Vigneswaran, K., Wang, Y., & Savvas, M. (2021). Socioeconomic status and fertility treatment outcomes in high-income countries: a review of the current literature. Human Fertility, 26(1), 1–11. https://doi.org/10.1080/14647273.2021.1957503

11. kffcarenec. (2024, October 9). 2024 Employer Health Benefits Survey | KFF. KFF. https://www.kff.org/health-costs/2024-employer-health-benefits-survey/

12. Bill Text - SB-729 Health care coverage: treatment for infertility and fertility services. (2023). Ca.gov. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240SB729