Is infertility a pre-existing condition?

Asked by: Estevan Denesik  |  Last update: June 15, 2025
Score: 4.6/5 (10 votes)

The bad news first: Infertility treatment is not one of the essential health benefits mandated by the ACA. If your health insurance did not cover fertility treatments before, it does not have to now. Now for the good news. Infertility is considered a pre-existing condition.

Is infertility considered a pre-existing condition?

The Affordable Care Act and how it may help you

However, there is good news too. Infertility is classified as a pre-existing condition. Before the Affordable Care Act, a pre-existing condition could have meant that you would be denied health insurance.

Can infertility be covered by insurance?

California's Knox-Keene Health Care Service Plan Act of 1975 does not require health insurance policies to cover infertility treatment. Instead, it requires that insurers offer employers the option to add general infertility treatment to their policies.

Is infertility considered a medical condition?

Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. Infertility may occur due to male, female or unexplained factors.

Is being pregnant considered a pre-existing condition?

According to Healthcare.gov, pregnancy is not considered a pre-existing condition. So if you were pregnant at the time that you applied for new health coverage: You can't be denied coverage due to your pregnancy. You can't be charged a higher premium because of your pregnancy.

What Is a Pre-existing Condition?

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What qualifies as a pre-existing condition?

Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan.

Can I add my wife to my insurance if she is pregnant?

Even if your wife's pregnancy began before she was insured under your health insurance policy, her maternity care must be covered. Also, having a child qualifies you for a special enrollment period. So, if your spouse isn't on the health plan, you can add her to the coverage if she's pregnant.

Is infertility a disability?

Infertility and related conditions are considered disabilities under federal (ADA) and California state law (FEHA), offering protection against workplace discrimination. Employees are entitled to reasonable accommodations, including time off for IVF and other fertility treatments, under the ADA, FEHA, FMLA, and CFRA.

Is infertility a qualified medical expense?

Any cost to you for treatment of a medical condition, including most physician visits, medications, and medical procedures. Artificial insemination, in vitro fertilization (IVF), and the temporary storage of eggs and/or sperm are deductible medical expenses.

Is infertility a medical diagnosis?

If you're younger than 35, your healthcare provider may diagnose infertility after one year (12 months) of trying to conceive. Trying to conceive is defined as having regular, unprotected sex. If you're 35 or older, your provider may diagnose infertility after six months of regular, unprotected sex.

How to qualify for IVF?

IVF is an option if you or your partner has:
  1. Blocked or damaged fallopian tubes.
  2. Endometriosis.
  3. Low sperm count or other sperm impairments.
  4. Polycystic ovary syndrome (PCOS) or other ovarian conditions.
  5. Uterine fibroids.
  6. Problems with your uterus.
  7. Risk of passing on a genetic disease or disorder.
  8. Unexplained infertility.

Is PCOS covered by insurance?

No insurance coverage: While some insurance policies do not cover fertility treatment, most health insurance policies will at least cover diagnosis and treatment of underlying conditions that may cause infertility, such as polycystic ovary syndrome (PCOS), endometriosis, fibroids, and certain conditions for men, such ...

Does insurance cover infertility?

California law requires insurers and health care service plans to offer coverage of infertility treatment, except IVF. * Cal. Health & Safety Code § 1374.55; Cal Ins. Code § 10119.6.

How many months of trying is considered infertile?

For public health data collection, infertility is defined as not being able to get pregnant (conceive) after 1 year (or longer) of unprotected sex. Fertility in women is known to decline steadily with age. As a result, some providers evaluate and treat women aged 35 years or older after 6 months of unprotected sex.

Is pregnancy a pre-existing condition for STD?

Individual STD policies require medical underwriting, and pre-existing conditions are typically excluded. If you apply during your pregnancy, it will be considered a pre-existing condition. While the insurance company may write the policy, any disability or claim relating to pregnancy will likely be excluded.

Why do insurance companies not cover infertility treatments?

Reasons that insurance companies give for why ART should not be covered include the following: in/fertility treatments are experimental, they do not treat an underlying disease but rather produce a desired outcome (i.e., a child), and they are an elective procedure not a medical one [8].

Can I claim my pregnancy on my taxes?

To qualify for pregnancy-related tax deductions you will need to keep accurate records and receipts of your health related expenses such as receipts from your doctor visits, necessary medical equipment, hospital visits and medication, to name just a few of the qualifying medical expenses.

How do you pay for infertility?

How can you make IVF more affordable?
  1. Check your health insurance coverage.
  2. Look into your state's laws.
  3. Apply for IVF grants.
  4. Budget and save money.
  5. Shop around.
  6. Ask about package deals.
  7. Check for potential refunds and shared-risk programs.
  8. Deduct IVF costs from your taxes.

Can you sue for infertility?

Fertility lawsuits can be filed by various individuals, depending on the circumstances. Individuals or couples who have experienced fertility-related issues due to medical negligence, misdiagnosis, or errors in assisted reproductive technologies may file lawsuits.

How long should I take off work for IVF?

You shouldn't go back to work the same day, but after that the amount of time you take off for recovery is up to you. Many women feel well enough to go back to work the day after their egg retrieval, while others give themselves a bit more time to rest.

What pre-existing conditions are not covered?

Is there health insurance for pre-existing conditions? Choosing a health plan is no longer based on the concept of a pre-existing condition. A health insurer cannot deny you coverage or raise rates for plans if you have a medical condition at the time of enrollment.

What can I claim when pregnant?

Statutory Maternity Leave

If you are employed and pregnant, you are entitled to 52 weeks (1 year) of maternity leave, no matter how long you've worked for your employer. This is made up of 26 weeks of ordinary maternity leave and 26 weeks of additional maternity leave.

Is pregnancy a pre-existing condition?

At that time, many health plans considered pregnancy a pre-existing condition. Health plans can no longer deny you coverage if you are pregnant. That's true whether you get insurance through your employer or buy it on your own. What's more, health plans cannot charge you more to have a policy because you are pregnant.