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» How to Cover Infertility Expenses with an Infertility HRA

November 18, 2021

ACA, Business Strategies, Health Equity, Healthcare Innovation, Healthcare Spending, Self-Funding

Much has been said about declining birthrates throughout the developed world.

The CDC has found that the US had its lowest birth rate in over 30 years as of 2018. The effects of this are not just the longer people are waiting to have children, but also fertility issues. And these issues are well known by Americans, as 33 percent of people have turned to fertility treatments or know someone who has.


  • 1 in 8 couples experience obstacles in their fertility
  • 12 to 15 percent of couples are unable to conceive after a year of unprotected sex
  • 12 percent of women have difficulty becoming pregnant or carrying a baby to term

(Data via the CDC, CHHD, HHS, NIH, and Pew Resesarch.)

These statistics are sobering and really drive home how connected infertility issues are to declining birth rates and emotional anguish and anxiety around fertility.

How Employer Benefits Currently Address Infertility

With this current state for people exploring pregnancy, how do employer benefits measure up?

Not well.

Fertility coverage is not a nationally mandated benefit, and many states require it to just be available, sometimes at prohibitively high costs.

California’s mandate, for example, requires insurers to simply offer coverage. The way infertility riders are designed, every employee pays a higher premium and the employees who would use those services receive a meager benefit.

Consider this:

  • Only 13 states require employers to provide health insurance for IVF
  • Only 6 states require employers to provide medical insurance coverage for fertility preservation services such as egg freezing
  • 56 percent of employers with more than 500 employees offer some type of infertility coverage, however…
  • The percentage of employers offering IVF coverage fell from 2014 to 2018, down from 26 percent to 24 percent

(Data via the American Society for Reproductive Medicine, Mercer, and SHRM.)

The ethical and business case is clear for addressing a major source of stress and health issues for employees in today’s market. Mercer found turnover to be 5 percent lower in companies with fertility coverage compared to those that didn’t offer a fertility benefit.

So, being benefits consultants and this being a healthcare issue, how can employers design health plans that make an impact on employees and families dealing with these issues in establishing and growing their families?

Set Up an Infertility Health Reimbursement Plan or Infertility HRA

One strategy we see employers pursuing today is establishing an Infertility Health Reimbursement Plan or Infertility HRA.

This is a Health Reimbursement Account that is specifically designed to reimburse employees who incur costs for infertility services.

Setting Up and Submitting Claims for an Infertility HRA

In setting up such a plan, an employer sets an HRA dollar amount that is available, most commonly, annually, but could also be monthly or quarterly. This could be anywhere from $10,000 to $20,000 or more. The key here is that the employer only pays for claims that are actually incurred, so this is a limited self-funded benefit to employees.

The group establishes an Explanation of Benefits that includes specific keywords and phrases for eligible expenses and communicates this plan to employees. The EOB includes an “out of pocket” requirement for eligible expenses.

Infertility HRA enrollees use their designated technology platform (HSA/FSA/HRA vendor for example) to file eligible expenses for HRA reimbursement. Enrollees must be covered by an employer-sponsored health plan so as not to run afoul of ACA rules (see below).

Since infertility expenses do fall into the §213(d) IRS category, employers will align their HRA with an FSA plan. Employees thus have access to other pre-tax savings for their infertility expenses.

Examples of Infertility Expenses for an Infertility HRA

As the Infertility HRA is designed to supplement the health plan specifically when it comes to infertility services, it’s important to understand that the company has choice for what to cover and not cover.

Examples of services to cover or not cover include:

  • In-vitro fertilization (IVF)
  • Egg or sperm donor expenses
  • Sperm or egg freezing
  • Intrauterine insemination (IUI)
  • Gamete intrafallopian transfer (GIFT)
  • Zygote intrafallopian transfer (ZIFT)
  • Pre-implantation genetic testing (PGT)
  • Embryo transfer
  • Hysteroscopy
  • Laparoscopy
  • Ovarian stimulation
  • Semen analysis
  • Testicular sperm aspiration or extraction
  • Operations to reverse a prior surgery such as a vasectomy

ACA Considerations for an Infertility HRA

Compliance is important when offering any benefit and must be a starting point for plan design.

In order to satisfy ACA concerns, an Infertility HRA should only be available to employees currently enrolled in the employer’s health plan or verified to be enrolled in another employer-sponsored health plan that meets ACA requirements. This integrates it with the employer’s health plan so it does not violate ACA requirements around annual or lifetime limits and preventative services.

One important point is that because infertility expenses are considered a medical expense for tax purposes, employer reimbursement for these services is a group health plan and subject to the federal laws that apply to any medical plan. This includes ERISA, HIPAA, COBRA, IRC, ACA, and more as the situation demands.

Labor & Employment Law Considerations for an Infertility HRA

An Infertility HRA must adhere to many administrative and compliance requirements beyond the ACA, including ERISA plan documentation, SPD, COBRA and COBRA election rights,, Section 105(h) nondiscrimination testing, HIPAA and more.

Most companies work with a vendor to manage these plans and maintain the necessary plan documents and adhere to best practices to stay compliant with the various laws and regulations today.

Compatibility between HDHPs, HSAs, and Infertility HRAs

A company with employees enrolled in a high deductible health plan must understand how certain benefits could threaten an employee’s HSA eligibility. For these employees, the infertility HRA must be a post-deductible benefit, meaning the HRA would not pay benefits until the employee satisfied the statutory minimum deductible for that year in expenses. For 2021, that figure is $1,400 for employee-only coverage and $2,800 for family coverage.

If the HRA was not structured as a post-deductible benefit, then employees would be ineligible to make or receive HSA contributions.

“Do infertility expenses excluded from the health plan count towards the deductible?”

No, the deductible for the high deductible plan must be met with other medical expenses in the plan year.

Infertility HRA or Self-Funded Health Plan 

The Infertility HRA is mostly a strategy for the fully-insured health plan, which must otherwise offer a carrier’s specific IVF or other infertility rider. These riders are typically narrowly designed, limited in benefit, and offer little to no customization.

Employers with Self-Funded Health Plans have near-total control over their benefits plans and can include infertility services as covered benefits in their plan document. This inclusion may affect the structure and cost of their stop-loss insurance, so this conversation calls for a wider scope of overall health plan strategy.

Speak with one of our consultants today to learn how you can implement an Infertility HRA at your company

Additional Information

Jeanne Sager “What are the 2021 Fertility Statistics I Need to Know About?” CoFertility. Published Sep 3 2021.

Please note that the information above is intended to provide general information about employee benefits. This discussion is not an analysis of any specific plan and should not be construed, nor is it intended to provide, legal advice. If you have questions about this topic or those related to it, consult with your legal professionals who provide you legal advice specific to your situation.

Posted by in ACA, Business Strategies, Health Equity, Healthcare Innovation, Healthcare Spending, Self-Funding