Are Fertility Treatments Covered by Medicare?
This information is current as of July 27, 2022.
Many couples struggle to conceive and find support and success through fertility treatments. These treatments aren’t cost-effective for most. You may be asking, are fertility treatments covered by Medicare?
Medicare can cover fertility treatments if your physician declares it a medical necessity. This would be covered mainly under Medicare, Parts A, and B, which we’ll discuss in detail below. On the other hand, fertility drugs are usually not covered by Medicare.
Let’s dive into the different parts of Medicare that can help you cover the cost of specific fertility treatments.
What Is Medicare?
Medicare is a federal insurance program for people aged 65 and older, some younger people who have disabilities, and people who have End-Stage Renal Disease. End-Stage Renal Disease is permanent kidney failure that requires dialysis or a transplant.
Parts of Medicare
Medicare is divided into three parts: Part A, B, and D.
Medicare Part A is hospital insurance that covers inpatient hospital stays, hospice and end-of-life care, skilled nursing facilities, and assistance in the home.
Medicare Part B is medical insurance covering some doctors’ services, preventive services, medical supplies, and outpatient care.
Medicare Part D covers different prescription drugs. It also includes coverage for recommended vaccines or shots.
Choosing Your Medicare Coverage
Once you enroll in Medicare, you can decide what coverage you want and choose between regular Medicare or Medicare Advantage.
Original Medicare means you get Medicare Part A hospital insurance and Medicare Part B medical insurance. You pay a deductible at the beginning of each year that equals up to 20% of the cost as you receive medical services. Most of the cost of covered healthcare services and supplies is covered by Original Medicare.
On the other hand, Medicare Advantage is approved by Medicare but offered by a private company. The plans are bundled to include Part A hospital insurance, Part B medical insurance, and, usually, Part D prescription drug coverage. These bundles can sometimes offer vision, dental, and hearing coverage.
When Are Fertility Treatments Covered by Medicare?
Medicare covers fertility treatments if they are reasonable and necessary services for the treatment of infertility. According to the Centers for Disease Control and Prevention, CDC infertility means a woman cannot get pregnant after one year or longer of unprotected sex. These treatments must be deemed a medical necessity by your doctor.
If you are under 65 years old, have a disability, receive Medicare (Parts A and B). A physician recommends fertility treatment options to help you conceive. You would be covered for inpatient hospital stays under Medicare Part A. Medicare Part B would pay for certain doctors’ services, medical supplies, outpatient care, and medically necessary fertility treatments but will not pay for IVF or in vitro fertilization.
If your physician prescribes fertility drugs, you may have a more challenging time being covered by Medicare. Some medications your physician may prescribe to address ovulation problems include Clomid, Metformin, and Bromocriptine, to name a few. Unfortunately, most prescription drug plans under Part D exclude fertility drugs.
To receive Medicare coverage for fertility treatments, your doctor must prove infertility with processes that may include:
- Genetic testing
- CAT or MRI scans
- Testicular biopsies, semen analysis, or testosterone level testing for men
For women, tests may include thyroid tests, postcoital screenings to help understand your reproductive system, and several hormone tests.
Different Types of Fertility Treatments
Some fertility treatments include:
- Fertility drugs
- Intrauterine insemination (IUI)
- In vitro fertilization (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Gamete intrafallopian transfer (GIFT), and
- Zygote intrafallopian transfer (ZIFT)
A lot of fertility drugs work to address problems with women’s ovulation. These drugs can include:
- Human menopausal gonadotropin (hMG)
- Clomid, follicle-stimulating hormone (FSH)
- Metformin, gonadotropin-releasing hormone (Gn-RH), and
Some of these are taken by mouth and others are injected.
IUI is often called artificial insemination. This procedure inserts a specially prepared sperm into a woman’s uterus. Sometimes, women are given medicines to stimulate ovulation before IUI. This fertility treatment is used with couples with unexplained or mild male factor infertility.
IVF, ICSI, GIF), and ZIFT are all forms of assisted reproductive technology, also called ART. According to the CDC, about 2% of all infants born in the U.S. every year are conceived using ART. This technology helps many people conceive who otherwise can’t.
IVF is the most common form of ART. This process is when eggs and sperm are combined outside the body in a laboratory to create embryos and then are transferred into the woman’s uterus.
ICSI is a type of IVF used for couples with male factor infertility. This process involves injecting a single sperm into a mature egg, or the egg and sperm are placed in the same petri dish. The sperm fertilizes the egg on its own.
GIFT is when eggs and sperm are transferred into a woman’s fallopian tubes, and fertilization occurs within the woman’s body.
ZIFT occurs in a laboratory, and the embryo is transferred to the woman’s fallopian tube instead of her uterus. Both processes are not common in the U.S. To find out more about infertility treatments, see here.
Applying for Medicare
You can apply for Medicare online or by phone, or by heading to a local office.
The easiest way to apply for Medicare is to apply online. You will be prompted to answer a few questions to ensure you qualify. If so, you can continue your online application. You can also apply over the phone by calling 1-800-772-1213.
You can apply in person at your nearest Social Security office. Click here to search for the closest office in the area by zip code.
If one of the members of the couple works or once worked for a railroad, they can also apply for Medicare through the Railroad Retirement Board. To do so, call 1-877-772-5772.
Not all fertility treatments and drugs are covered by Medicare. Unfortunately, fertility drugs are usually not covered by Part D of Medicare.
In some cases, through the recommendation of your physician, you may be able to receive fertility treatment options that are covered through Medicare, Parts A and B.
Trying to conceive can be a challenging process. Fertility treatments help thousands of women become mothers for the first time every year. If this sounds like it could be you or your partner, schedule an appointment with your Medicare doctor to discuss the possibility of receiving Medicare-covered fertility treatments today.
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