Fertility issues are not an issue for most Medicare beneficiaries. By the age of 65, most of us have either already had kids or didn’t want a family. However, Medicare is not just for seniors.
Over nine million people receive Medicare through Social Security and can do so as early as age 18. If you are at the typical age range for having children but you are unable to conceive, Medicare does cover certain fertility treatments. However, treatment is highly dependent on your condition. In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we will go over the distinctions that would qualify you for fertility treatment.
- Infertility is considered an atypical condition that needs treatment if you are at an age that is typically expected to be fertile, which is before your 40s.
- If your infertility is not due to an underlying condition, your doctor will recommend positive lifestyle changes before further treatment options.
- Medicare Part B can provide coverage for fertility treatments if your doctor is able to prove that your infertility is atypical.
- Medicare Part B will fully cover diagnostic lab tests if your doctor orders them as part of your medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. infertility treatment.
- Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... does not cover any fertility treatment medications.
- Medicare Advantage PlansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will also cover the same services as Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. (Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part) as long as your doctor can prove that your infertility is atypical.
How Does Infertility Happen?
Infertility is a normal part of the aging process where women and men experience menopause and andropause, respectively, which significantly affects their body’s hormonal functions. However, these changes normally occur for people in their late 40s and above. It is considered atypical to experience infertility symptoms when you are in your 20s and 30s. You may be infertile if you experience:1Mayoclinic.org, “Infertility: Symptoms & Causes“, Accessed December 23, 2021
- Unsuccessful attempts at conceiving for six consecutive months
- Family history of fertility issues
- Sexual impotence
- History of irregular, absent, or painful periods
- Endometriosis (pelvic inflammatory disease)
- Multiple miscarriages
- Low-sperm count
- History of testicular and/or prostate issues
Lifestyle Changes For Improving Fertility
If you do not test positive for a medical condition that could cause infertility (cancer, cysts, etc.), your physician will likely recommend you make healthy changes to your lifestyle to increase the chance of conception before considering medication and/or surgery. Lifestyle changes that can increase your chances of conception include:2Mayoclinic.org, “Infertility: Diagnosis & Treatment“, Accessed December 23, 2021
- Eliminating certain medications that reduce fertility
- Ending drug and alcohol use
- Eating a healthier diet
- Getting regular sleep
- Getting regular exercise
- Timing intercourse with your ovulation cycle
- Increasing the frequency of intercourse
When Does Medicare Cover Fertility Treatments?
If your doctor determines fertility treatment is medically necessary, Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. may cover infertility services. Each situation is unique, so the rules and costs vary by case. If your infertility diagnosis is a symptom of an underlying medical condition (cancer, cysts, etc.), your treatment is likely covered by Medicare.3CMS.gov, “Medicare Benefit Policy Manual“, Accessed December 23, 2021
For Medicare to consider coverage, your doctor must first prove infertility in someone who should be otherwise fertile3CMS.gov, “Medicare Benefit Policy Manual“, Accessed December 23, 2021. Medicare-approved diagnostic testing for a man could include semen analysis, testosterone level testing, testicular biopsies, genetic testing, or CAT or MRI scans. For women, there are a variety of Medicare-approved fertility tests, including hormone tests, thyroid tests, and postcoital screenings.4Medicare.gov, “Diagnostic laboratory tests“, Accessed December 23, 2021
Note: Although Medicare covers some fertility treatments, In Vitro Fertilization (IVF) is not covered.
Medicare Part D Fertility Medications
A Medicare Part D plan provides coverage for most prescription drugs the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. needs5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 23, 2021. However, Part D excludes coverage of fertility medications. This includes medications like Clomid which is considered a fertility medication.6Goodrx.com, “Clomid“, Accessed December 23, 2021
With that said, Part D plans are still useful for covering other prescription medications you need. Depending on the plan, you may have to pay an annual deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. before Part D begins paying its share, as well as a co-payment with each prescription.5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 23, 2021
Since Medicare Advantage plans are only required to cover what Original Medicare (Part A and Part B) covers, then they are also only required to cover fertility treatments that your doctor considers medically necessary. If that is the case, Medicare Advantage Plans will provide fertility treatments within their network of service providers.7Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 23, 2021
Some Medicare Advantage Plans also come with prescription drug coverage, as well as expanded benefits not normally covered by Medicare, such as vision and dental services. When shopping for a plan in your area, ask the plan provider if their formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered. (covered drugs list) includes fertility medications as an expanded benefit that Medicare Part D normally doesn’t cover.7Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 23, 2021
Medicare will only cover fertility treatments if you are within a reasonable age range that should be able to conceive with minimal issues. Even if your doctor provides evidence that your fertility treatment is medically necessary, Part D drug coverage will not cover any fertility drugs your doctor prescribes.
- 1Mayoclinic.org, “Infertility: Symptoms & Causes“, Accessed December 23, 2021
- 2Mayoclinic.org, “Infertility: Diagnosis & Treatment“, Accessed December 23, 2021
- 3CMS.gov, “Medicare Benefit Policy Manual“, Accessed December 23, 2021
- 4Medicare.gov, “Diagnostic laboratory tests“, Accessed December 23, 2021
- 5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 23, 2021
- 6Goodrx.com, “Clomid“, Accessed December 23, 2021
- 7Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 23, 2021