2021 survey on

fertility
benefits
welcome to brighter

content
Introduction .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3About the survey  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4Prevalence of coverage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5Employers providing infertility coverage .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6Employers that do not provide infertility coverage .  .  .  .  .  .  .  . 11
Conclusion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13

Updated May 4, 2021

2021 Survey on Fertility Benefits

3

Introduction
For many years, there was no discernible upward trend incoverage for infertility treatment in employer health plans.
Throughout the 2000s and early 2010s, Mercer’s National Surveyof Employer-Sponsored Health Plans consistently found thatfewer than a fourth of large employers (those with 500 or more
employees) covered in vitro fertilization (IVF), one of the mostimportant fertility services. While the biggest employers –those with 20,000 or more employees – were somewhat more
likely to provide these coverages, again, there was little growthover time. Given the ongoing challenge of managing rising
health benefit costs, the majority of employers, it seemed, werereluctant to assume the direct cost of coverage and the added
risk for high-cost claims from multiple births.

But that is changing. Over the past five years we’ve begun to see a new
focus on fertility benefits of all kinds among the largest employers – driven
by improvements in treatment protocols, shifts in workforce demographics,
a sharper focus on inclusivity, and a broader definition of what constitutes
health and well-being. Since the largest employers are often trendsetters, it
seems likely they are the leading edge of a broader movement – especiallysince the vast majority of survey respondents – 97% – say that adding
infertility coverage did not result in a significant increase in medical plan cost.
There is also increasing activity by state and federal governments
to improve access to infertility treatment. In the past four years,
four states have passed laws to provide coverage, bringing
the total number of states with infertility insurance laws to 19.
At the federal level four years ago, Congress authorized theVeterans Administration to offer IVF care to wounded veterans,
and several legislative proposals have been introduced to coverinfertility services through government-sponsored health plans
as well as commercial insurance.

Defining infertility
In 2017, the American Medical Association
recognized infertility as a disease, years
after the World Health Organization
classified infertility as a disease in 2009.
Infertility is defined as the inability toachieve pregnancy after one year of
regular, unprotected sexual intercourse,
unless medical history, age, or physicalfindings dictate earlier evaluationand treatment.
According to the Centers for Disease
Control and Prevention, one in eight
women of childbearing age havedifficulty conceiving or carrying apregnancy to term. However, thisestimate does not account for LGBTQ+
or single individuals who may also needfertility treatments to build their families
but do not meet this heteronormative
definition of infertility.
RESOLVE: The National Infertility
Association developed and vetted
the following inclusive definition ofinfertility, used in its model legislationand model benefits for employers:“Infertility” means a disease, condition
or status characterized by:•	the failure to establish a pregnancy
or to carry a pregnancy to live birth
after regular, unprotected sexualintercourse, or•	a person’s inability to reproduce either asa single individual or with their partner
without medical intervention, or•	a licensed physician’s findings basedon a patient’s medical, sexual andreproductive history, age, physicalfindings and/or diagnostic testing.

2021 Survey on Fertility Benefits

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About the survey
The Survey on Fertility Benefits was sent as a follow-up to
participants in Mercer’s National Survey of Employer-Sponsored
Health Plans to collect more detailed information about fertility
benefits. In the National Survey, which was conducted in thesummer of 2020, employers were asked one question about
the types of infertility treatment covered under their mostprevalent plan. Their responses to that question were includedin the follow-up survey. Respondents were asked to confirm
or update their earlier response. Based on their answer to thatquestion, respondents were given one of two sets of questions;
one designed for employers that cover infertility treatment(or at least an evaluation by a reproductive endocrinologist or
infertility specialist) and one designed for employers that do
not provide any coverage.

The survey was fielded in February 2021. To reduce the risk ofnon-response bias, the invitation did not specify the topic of
the survey. Overall, 459 employers responded. Just over halfof the respondents – 254 employers – provide some level ofcoverage; 205 respondents do not provide any coverage.
The Survey on Fertility Benefits was commissioned by RESOLVE:
The National Infertility Association. It is the second such survey
commissioned by RESOLVE. The first was conducted in 2006,
and one of the goals of this current study is to assess how
employer offerings and attitudes have changed since that time.

2021 Survey on Fertility Benefits

5

Prevalence of coverage
For estimates of the prevalence of infertility coverage in the US, we draw on
results from Mercer’s National Survey, which are weighted to represent all
US employer health plan sponsors with 50 or more employees. The rest of
the report is based on results collected through the follow-up survey.
According to Mercer’s National Survey of Employer-Sponsored
Health Plans, whether or not an employer covers infertility
coverage is strongly related to their size. About a third (32%)
of small employers, those with 50-499 employees, coversome type of infertility service, compared with 61% of large
employers, those with 500 or more employees.
Even when employers provide some fertility benefits, in manycases coverage is limited to an evaluation by an infertility

specialist and does not extend to procedures to achieve apregnancy. However, over the last five years we’re beginning tosee expansion in the services covered, particularly IVF. Among alllarge employers, the prevalence of this coverage has risen from
24% in 2015 to 27% in 2020, and even among smaller employers it
has reached 14%. Importantly, among jumbo employers – thosewith 20,000 or more employees – coverage for IVF is approaching
the halfway point, rising from 36% to 42%.

Coverage of fertility benefits is growing, especially among the largest employers
Employers with 500 or more employees

Employers with 20,000 or more employees

2015

2020

2015

2020

Evaluation by a reproductive
endocrinologist or infertility specialist

54%

58%

70%

73%

Drug therapy

32%

33%

44%

53%

In vivo fertilization(intrauterine insemination)

23%

28%

34%

38%

In vitro fertilization

24%

27%

36%

42%

Egg freezing

5%

11%

6%

19%

No coverage provided

40%

39%

23%

23%

Source: Mercer National Survey of Employer-Sponsored Health Plans

Jumbo employers are also out in front in providing coveragefor elective egg freezing: In 2020, nearly a fifth (19%) provide
this coverage, up from just 6% five years earlier, in 2015. The
prevalence of this benefit also varies by industry. For example,
among all employers with 500 or more employees, 11% cover
egg freezing. Among respondents of this size in high-techindustries, however, 27% cover egg freezing, perhaps in aneffort to improve attraction and retention of female employees.

Of the 459 employers responding to the follow-up survey on
fertility benefits, 55% offer some level of coverage and 45%
don’t offer any coverage. Not surprisingly, large employers are
more strongly represented in the group that offers coverage(80% have 500 or more employees) than in the group that
doesn’t (64% have 500 or more employees).

2021 Survey on Fertility Benefits

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Employers providing
infertility coverage
Results are based on 254 respondents that cover an evaluation with areproductive endocrinologist and/or various fertility treatments. About
three-fourths (74%) of these respondents provide coverage for some formof treatment beyond an evaluation.
The three reasons for covering infertility treatment cited by
the most respondents (about 50% for each) were to “ensure
employees have access to quality, cost-effective care,” “staycompetitive to recruit and retain top talent,” and “be recognized
as a “family friendly” employer”. Interestingly, these were also
the top three reasons cited for offering coverage by respondents
to the 2006 survey. However, 63% of respondents in 2006 said
they provided infertility benefits “to generate positive public
relations,” compared to just 16% of respondents to the current
survey. This may be because infertility benefits are morecommon today and no longer seen as newsworthy.

On the other hand, two-fifths of respondents (40%) offer
coverage to “support diversity, inclusion and equity (DEI)efforts,” a response option that was not included in the 2006
survey. This was more common among larger employers -nearly half of employers with 5,000 or more employees have thisobjective, compared with 33% of those with 10-499 employees.
Additionally, respondents that have added coverage within thelast two years are more likely to have done so in support of DEI:
61% of respondents cited it as a primary objective, comparedwith 24% of respondents that have offered coverage for morethan five years.

Objectives for providing fertility benefits
Ensure employees have accessto quality, cost-effective care

51%

Stay competitive to recruitand retain top talent51%

Be recognized as a “family
friendly” employer

50%

Support Diversity, Inclusion
and Equity efforts

40%

Respond to employee requests

34%

We see coverage for infertility treatment
as an aspect of maternity benefits

32%

Mitigate the risk of high-risk
pregnancies (multiple births)

17%

Generate positive public relations
We cover infertility to comply
with state law
Survey on Fertility Benefits 2021

16%
9%

2021 Survey on Fertility Benefits

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Outcomes achieved
Employers were also asked to what extent offering infertility
benefits has helped the organization achieve a number ofpossible positive outcomes (whether or not the outcome was
identified as an objective for offering the benefit). At the top of
the list of outcomes was “ensuring access to quality, cost-effectivecare” – 71% report that their infertility benefits have achieved
this outcome to a significant or moderate extent. Second was“satisfying employee requests,” cited by 64% of respondents.
However, for all the possible outcomes included in the question,
we see a sharp contrast between employers that cover IVF andthose that do not. Employers are almost twice as likely to reportachieving a positive outcome if they cover IVF. For example,
81% of those covering IVF report success in satisfying employee
requests, compared to just 44% of those not covering it. In termsof supporting DEI efforts, the difference is even greater: Only
27% of those not covering IVF believe that their current infertility
coverage offering has helped to advance DEI goals, compared to79% of those covering IVF.

Offering infertility coverage has helped
achieve the following outcomes*
Ensuring employees have access toquality, cost-effective care

71%

Satisfying employee requests

64%

Staying competitive in attracting
and retaining talent

62%

Recognition as a “family friendly” employer

59%

Supporting Diversity, Inclusion
and Equity efforts

55%

Mitigating the risk of high-risk pregnancies

49%

Positive public relations

40%*to a significant or moderate extent

Cost impact of offering infertility coverage
Employers were asked if covering infertility benefits resulted in a measurable,
significant increase in medical plan cost.

97%

Virtually all respondents said they havenot experienced a significant cost increase,and this includes employers that currently
cover IVF.
In our 2006 survey, 91% responded this way, so negative cost consequences appear
to be even less of an issue now than they were 15 years ago.

2021 Survey on Fertility Benefits

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Concerns about the cost of IVF coverage remain a barrier, but thesesurvey results suggest that some employers may assume that thecoverage costs more than it actually does.

Adding IVF coverage
The survey found that a substantial portion of employers are interested
in expanding their fertility benefit offerings. Of the respondents that
do not currently cover IVF, almost a fifth say they are likely to add thiscoverage in the next two years (50% say they are not likely, and therest don’t know). Of the respondents that do not currently cover egg
freezing, 12% are likely to do so within the next two years. In the 2006
survey, just 5% of respondents that did not offer IVF were considering
adding it, which suggests that momentum is building.
Very likely

Somewhat likely

Not likely

Don’t know

4%

32%

14%

Likelihoodof addingcoverage for IVF
Among respondents thatprovide infertility coverage,
but do not cover IVF

50%
1%

36%

11%

Likelihood of
adding coveragefor egg freezing
Among respondents thatprovide infertility coverage,
but do not cover
egg freezing
52%

Survey on Fertility Benefits 2021

2021 Survey on Fertility Benefits

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Infertility coverage limits
Most respondents (88%) place some type of limit on infertility
treatment coverage. While the most common type of limitationis still a lifetime maximum dollar benefit (used by 60% of
respondents), 13% now choose to place a limit on the number of
IVF cycles covered, with the median number of cycles covered
being three. Coverage limitations based on the number ofcycles rather than a flat dollar amount is considered bestpractice. Multiple cycles may be needed to achieve a successful
pregnancy, and if the dollar amount provided will only pay
for one cycle, as is often the case with dollar limits, there’s an

incentive to transfer multiple embryos in hopes of maximizing
the chance of getting pregnant in just one cycle. This increases
the chance of multiple births, which in turn raises health risks(and health care costs) for both the mother and the babies.
Among respondents with a lifetime maximum dollar benefit,
the median dollar limit is $16,250 among all respondents($20,000 among those with 500 or more employees), which
may or may not be enough to cover even one round of IVF ,depending on the state.

Limits on infertility coverage used
Limits on infertility benefits

60%

Median benefit
maximum$16,250

Median numberof cycles covered

3

28%
13%
A lifetime
maximum benefit

A limit on the numberof IVF cycles

12%
Other
limitations

No limitations

Survey on Fertility Benefits 2021

The Affordable Care Act bans dollar caps, so laws regarding infertility coverage that have passed since the ACA went into effect havenot included dollar maximums. Only three states of the 13 that mandate coverage for IVF allow a dollar cap, which was in place prior to
the ACA (this does not include Utah, which allows State Employees to use a $4,000 adoption benefit for infertility treatment).
Over a fourth of respondents (28%) have other limitations, such as a separate maximum on drug therapy and limits on egg storage.

Use specialty vendor to provide or
administer fertility services
Some respondents (12%) use a specialty vendor to administer
the benefit; examples include ARC Fertility, Carrot, Kindbody,
Progyny, and WIN Fertility. Others, such as Maven and Ovia,
specialize in member-facing tools and resources. Overall,
the specialty vendors tend to have more flexibility in theadministration of the benefit compared to traditional medical
carriers, provide enhanced coaching/member services, andare better equipped to navigate members to high quality
resources, ultimately improving outcomes. Use of a specialty
vendor is more common among larger employers: 21% of
respondents with 5,000 or more employees use a specialty
vendor, compared to 14% of those with 500 or more employees(and just 2% of those with 10-499 employees).

Supporting Diversity, Inclusion & Equity
Respondents that provide coverage for IVF or IUI were asked
if the benefit was specifically designed and communicated to
be available to LGBTQ+ or single employees. This would mean,for example, that a clinical diagnosis of infertility based onheterosexual intercourse would not be required for coverage.
Over a third (35%) of respondents say they designed the benefit
to be available to LGBTQ+ and/or single employees and madethat clear in the benefit communication.

2021 Survey on Fertility Benefits

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Other family friendly benefits
In addition to providing coverage for infertility benefits, nearly half of respondents (46%) provide financial support for adoption andnearly one in 10 (9%) provide financial support for surrogacy. Respondents that offer infertility coverage to support DEI were much
more likely to provide coverage for adoption (61%) and surrogacy (20%). Just 5% help pay for fertility treatment that is not covered by
the medical plan.

Family-friendly benefits offered or being considered61%

All respondents
Respondents offering	coverage to support DEI

46%

20%
5%

9%
Adoption

Survey on Fertility Benefits 2021

Surrogacy

6%

Fertility treatment not coveredby the medical plan

2021 Survey on Fertility Benefits

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Employers that do
not provide any
infertility coverage
Results are based on 205 respondents that do not cover an evaluation witha reproductive endocrinologist or any fertility treatments.
The reason most commonly given by survey
respondents for not providing infertility coverage
is cost. Over half (55 percent) do not offer coverage
because of “concerns about potential increased
costs.” Larger employers are more likely to cite cost
as a barrier than smaller employers: 60% of thosewith 500 or more employees, compared with 47%of those with 10-499 employees. About a third(35%) say there is “little demand for these services
from employees” and 13% are “concerned about
potential high utilization.” Some employers don’t
believe infertility benefits should be the employer’s
responsibility (13 percent) or are only willing toprovide basic coverage and they don’t believe
infertility treatment to be basic coverage (9%). A
handful of respondents don’t offer coverage forreligious reasons. As one respondent put it, “we area faith-based organization and fertility benefits goagainst our ethical and religious directives.”
It is interesting that while over a third of
respondents reported little demand for infertility
services, when asked about any issues createdby the lack of infertility coverage, 28% of all
respondents and 37% of those respondents with
500 or more employees say that employees haverequested it. This was the primary downside seen
by respondents; only a few reported problems
with recruitment and retention or public relations
stemming from the lack of coverage, and just
3% have experienced increased cost due to highrisk pregnancies.

Concerns about potential
increased costs

55%

Little demand for these
services from employees

35%

Concerns about potential
high utilization

13%
Don’t believe infertility
treatment should be theemployer’s responsibility

Our objective is to provide
basic coverage only,
and we don’t consider
infertility treatment to bebasic coverage

13%

9%

Other

20%

2021 Survey on Fertility Benefits

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Likelihood of adding infertility coverage
In our 2006 survey, only 7% of the respondents not offering any infertility coverage said they were at least considering it. In thecurrent survey, while very few small employers are considering adding it, about a fifth of the large employers are – with 18%
considering offering IVF and 15% considering IUI.

2006
Evaluation by a reproductive
endocrinologist or infertility specialist

2021

6%
18%

Drug therapy

4%15%

In vitro fertilization2%
18%

In-vivo fertilization(intrauterine insemination)

3%

Considering offering at least somecoverage for infertility

15%
7%
21%

Based on respondents with 500 or more employees

Nearly half of respondents (47%) said that if they knew the cost of covering infertility treatment would be offset by savings from
eliminating other medical plan costs, such as multiple births, they would be more likely to provide coverage. Without insurance
covering fertility treatments, employees paying out of pocket for these procedures typically try to maximize the chance ofpregnancy by transferring multiple embryos, which can lead to multiple births and time spent in a neonatal intensive care unit –expenses that would be covered by the employer’s plan.

Nearly half of respondents would be
more likely to provide fertility coverage
if they knew the cost would be offset bylower costs for multiple births.
Other family-friendly benefits offered
Nearly a quarter of respondents (24%) have considered providing financial support outside the medical plan for adoption. Just 3%
considered providing support for surrogacy and 2% for fertility treatment not covered by the medical plan.

2021 Survey on Fertility Benefits

Conclusion
It’s exciting to see more employers responding to the requests of theiremployees and recognizing the importance of fertility benefits aspart of a comprehensive program that seeks to support all aspects of
employee health and well-being. Certainly, employers are looking todistinguish themselves with more family-friendly and inclusive benefit
offerings. The birth rate among women over 40 has been increasing as
more working women delay having children, and fertility benefits havebeen shown to influence their employment decisions. When coverage
is not restricted to women and men in a heterosexual relationship,these benefits can also make an organization more attractive to
LGBTQ+ employees.
Employers that don’t offer fertility coverage should be advised: A2020 analysis of National Survey data found that the average turnoverrate in 2020 for large employers offering IVF was 18%, compared to
22% among employers not covering IVF. Of course, many employersthat offer IVF coverage offer more generous benefits in general, so
it’s likely not the only reason for lower turnover. But there is no doubt
whatsoever that access to comprehensive fertility coverage is highly
valued by those who need it. And the good news for employers
considering adding or enhancing their fertility benefits is that 97%
of survey respondents did so without experiencing any significant
increase in medical plan cost.

13© 2021 Mercer LLC. All rights reserved.