Managed care plans may revisit how they cover in vitro fertilization treatments in the wake of Aetna U.S. Healthcare's revision last week of a prior decision to withdraw coverage.
Aetna earlier this month announced that as of April 1 it was stopping coverage of IVF and other advanced assisted reproductive techniques, which it offered as part of its basic benefits coverage.
But last week, the health maintenance organization said it was clarifying its position and will continue to cover in vitro fertilization treatments, but only for employers that select it as an option and pay an additional premium. Some people have opted for the Aetna U.S. Healthcare plan offered by their employer specifically to take advantage of the benefit.
Aetna's reluctance to offer the coverage as part of basic coverage stems from its high cost, which can run $8,000 or more per treatment.
Proponents of the coverage say, however, that on a per-employee [TABULAR DATA OMITTED] basis, the cost is not significant because of the relatively few employees who use these treatments.
Although the decision of an employer to offer coverage of infertility treatments is voluntary and often based on corporate philosophy, that could change with several efforts under way.
One is a push by employees to have infertility defined as a disability under .the Americans with Disabilities Act, in which a failure to provide benefits could be seen as biased.
Moreover, a spokesman for the American Society for Reproductive Medicine in Washington said it will seek legislation to be introduced this year in Congress mandating infertility coverage.
To date, 13 states require health insurers and HMOs to cover some form of infertility insurance, but their provisions vary widely and do not necessarily include coverage of IVF treatment. They are: Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New York, Ohio, Rhode Island, Texas and West Virginia.
Self-insured employers, however, are exempt from state regulations under provisions of the Employee Retirement Income Security Act, though they would be subject to a federal law.
According to the current Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans of employers with 500 or more employees (see story, page 1), on a weighted average basis, 21% of them obtain coverage for in vitro fertilization through their health care plans, while 50% have coverage of some form of infertility treatment in general.
A paper released by William M. Mercer Inc. last year estimates that as of 1995, the cost to employers of adding IVF treatment to a standard health care benefits package would be $2.79 per member per year, and the premium would be $3.14.
In announcing that Aetna now plans to offer advanced reproductive technology services as an optional rider, Michael J. Cardillo, president of Aetna U.S. Healthcare, said the company is proud to have been a pioneer in voluntarily offering these benefits as part of its basic coverage.
'However, we recognize that decisions on benefits ought to be made by the employers who ultimately must fund them,' he said.
'It gives the employer more discretion over the design of the benefits in its HMO,' just as it now has for its POS and PPO plans, said Mary Case, a principal with the Kwasha Lipton Group of Coopers & Lybrand in Fort Lee, N.J. She anticipates Aetna's action will encourage other HMOs to reexamine whether this benefit should be included in basic coverage.
Infertility treatment coverage varies among managed care companies.
Norwalk, Conn.-based Oxford Health Systems Inc., for example, continues to offer advanced infertility coverage as part of its basic coverage in New York, with various monetary limits. But HIP Health Plan of New York has not offered IVF coverage for several years, a spokeswoman said.
Dr. Mitzi Krockover, vp of women's health for Louisville, Ky.-based Humana Inc., which offers IVF coverage as an optional rider, said, 'It's definitely on our radar screens in a big way.' She said she does not anticipate the company will eliminate it as an option, noting that competitive forces in the markets in which it operates will be a factor in how it proceeds.
Managed care companies are 'all under a lot of pressure for bottom-line numbers,' said Jim Berger, senior vp at Aon Consulting in New York. 'I think they're all going to be looking at big-ticket items that will come under the scrutiny of their medical directors and their financial people.'
He added that most employers that provide coverage 'do it either because their senior management either has a personal experience, or they just have a very pro-life view of the world.'
'It's a very expensive benefit and, unfortunately, it's one of those things where often if there is a benefit, there's more of an inclination to use it, even if the statistics (for success) are pretty pessimistic,' said Helen Darling, manger-international compensation and benefits for Stamford, Conn.-based Xerox Corp., which offers infertility coverage under its fee-for-service plan.
'To me, this is a pretty mainstream medical practice for people who want to have children and are having difficulty,' said Suzanne Mercure, manager of benefits administration for Rosemead, Calif.-based Southern California Edison Co., which also offers coverage.
'My impression is many large employers do incorporate infertility treatment but try to limit the exposure, because of concern that if they don't, the cost could be significant,' said Susan Margolis, a benefit consultant with Buck Consultants Inc. in New York. An example of such limitations, she said, could be limits on the number of covered treatment cycles.
Meanwhile, efforts are under way to have the courts declare infertility a disability under provisions of the Americans with Disabilities Act, which could create the argument that refusing coverage is discriminatory.
The ADA defines disability as a condition that substantially limits a major life activity, and courts are wrestling with the issue of whether reproduction falls into that category, with a mixed record to date.
A case scheduled for argument in the U.S. Supreme Court in March, Abbott vs. Bragdon, could have some impact. While it involves a woman denied dental treatment because she is HIV-positive, her attorneys are seeking to establish she is covered under the ADA because her HIV status means she cannot procreate due to the risk of passing on the disease to her baby and surviving to raise a child.
Ruling in her favor, the federal appellate court in Boston had concluded she is disabled.
The ADA, however, only calls for 'reasonable accommodation' for those with disabilities, and that does not necessarily include offering coverage for advanced infertility treatments, noted Terri Finesmith Horwich, a Chicago-based attorney with Bostick, Bush-Joseph & Horwich who specializes in reproductive technology and adoption cases. Employers and health care companies still would be entitled to apply reasonableness and medical necessity tests, she said.
