IVF is a medical procedure involving retrieving eggs and fertilizing them with sperm in a laboratory to create an embryo for transfer into the uterus. Since a single cycle of IVF, including medication and monitoring, can cost tens of thousands of dollars, access often depends on health insurance coverage. Because no federal law requires this coverage, some state governments have passed “insurance mandates” compelling state-regulated health plans to provide or offer fertility treatment benefits. These mandates create a patchwork of coverage across the U.S., making a patient’s residence a significant factor in their ability to afford family-building options.
States with Comprehensive Coverage Mandates
States requiring health insurance plans to cover IVF offer the most direct access for patients, though these mandates typically apply only to state-regulated, fully insured plans. As of late 2024, approximately 15 states and Washington D.C. have laws that specifically include IVF as a covered benefit, with a core group offering robust coverage.
Many comprehensive mandates are concentrated in the Northeast, including Connecticut, Delaware, Illinois, Massachusetts, Maryland, Maine, New Hampshire, New Jersey, New York, and Rhode Island. New York requires large group plans to cover up to three complete IVF cycles if the patient cannot achieve pregnancy through less expensive means. Colorado’s mandate requires coverage for three completed egg retrievals, which can result in an unlimited number of embryo transfers.
Other states, such as Arkansas and Utah, mandate some level of IVF coverage, but often with stricter criteria or limitations. Illinois requires coverage for up to four cycles of IVF or up to six cycles if a live birth has not yet occurred. Coverage varies widely, as legislative language defining the number of cycles, lifetime maximums, and patient eligibility differs across states.
Distinguishing Mandates to Offer and Mandates to Cover
Understanding the difference between a “mandate to cover” and a “mandate to offer” is crucial for determining access to IVF. A mandate to cover requires state-regulated health insurers to include IVF benefits in every policy sold. If an employer purchases a fully insured plan, the mandated coverage is automatically included, with costs distributed across all policyholders.
In contrast, a mandate to offer requires the insurer only to make an IVF-inclusive policy available for employers to purchase; it does not require the employer to buy it. If an employer opts for a plan excluding the fertility benefit, the employee will not have coverage. States like California, Texas, and Tennessee have historically used this model, placing the decision and cost burden on the employer.
This distinction significantly impacts consumer access. In a “mandate to cover” state like New Jersey, an employee of a fully insured company is generally guaranteed the benefit. In a “mandate to offer” state like Texas, the employee must rely on their employer’s voluntary decision. A mandate to cover thus provides a higher degree of certainty regarding access to treatment.
Common Eligibility Requirements and Limitations
Even in states with a strong mandate to cover IVF, access is not unlimited, and patients must meet specific criteria outlined in state law and policy. A primary limitation is the medical definition of infertility, typically requiring a patient to have failed to achieve a successful pregnancy after a specific period of unprotected intercourse. This period is often one year for patients under 35 and six months for those over 35.
Mandates often require patients to first exhaust less invasive treatments, such as ovulation induction medications or intrauterine insemination (IUI). For example, a patient in Connecticut may only be eligible for the mandated two IVF cycles after demonstrating that prior, covered treatments were unsuccessful. This ensures the procedure is only used after less costly options have failed.
State mandates often include explicit age restrictions or caps on the number of covered cycles. New Jersey’s law limits coverage to patients 45 years of age or younger, and Rhode Island imposes a $100,000 lifetime maximum benefit. Some state laws also contain restrictive language regarding the source of gametes, such as older mandates in Arkansas requiring the use of a spouse’s sperm, which can exclude same-sex couples and single individuals.
The Impact of Federal Law on State Mandates
The most significant exception to state-level IVF mandates involves the federal Employee Retirement Income Security Act of 1974, known as ERISA. This federal law governs most private-sector employee benefit plans and includes a provision that “preempts,” or overrides, state laws that attempt to regulate them. Consequently, state insurance mandates only apply to “fully insured” health plans, where an employer pays premiums to an insurance company, and the insurer assumes the financial risk.
Many large national companies utilize “self-funded” or “self-insured” health plans, which are directly regulated by ERISA. In a self-funded arrangement, the employer pays employee medical claims out of its own operating funds. Because these plans are exempt from state insurance regulations, an employee covered by a self-funded plan in a state with a comprehensive IVF mandate may not be entitled to the mandated coverage.
This ERISA preemption creates a substantial loophole, as approximately 61% of covered workers in the U.S. are enrolled in a self-funded plan. Determining whether a plan is fully insured or self-funded is a necessary first step for patients, even those residing in a state with a strong mandate. While some large, self-funded employers voluntarily offer comprehensive IVF benefits to remain competitive, they are not legally required to do so by the state.