Insurance Issues in Infertility Treatment
More than a dozen states require insurance companies to offer varying forms of benefits for fertility treatments. There are generally two kinds of benefits: one to "cover" fertility treatments and to "offer to cover" fertility treatments.
Insurance -- State Benefits
Several states have passed laws that require insurers to either cover or offer coverage for infertility diagnosis and treatment. While most states include coverage for in vitro fertilization, other states specifically exclude coverage for the procedure.
At the current time there is no federal law requiring insurance coverage for infertility treatment. Please note that coverage that we have listed below in reference to a state may change at any time. If a state is not listed here, or if you have questions about insurance laws in your state, please call your state's Department of Health, Insurance Commissioner's office or your State elected officials.
This law requires all health insurers that cover maternity benefits to cover the cost of in vitro fertilization (IVF). Health maintenance organizations, are exempt from the law.
Ark. Stat. Ann. §§ 23-85-137 and 23-86-118 (1987) requires health insurance companies to cover the expenses of in vitro fertilization procedures only. Allows insurers to impose a lifetime benefit cap of $15,000. Health maintenance organizations are exempt from the law.
IVF procedure must be performed at a medical facility licensed or certified by the Arkansas Department of Health. Those facilities certified by the Department of Health must conform to the American College of Obstetricians and Gynecologists guidelines for in vitro fertilization clinics or meet the American Fertility Society's (sic) minimal standards for programs of in vitro fertilization.
The IVF benefits are subject to the same deductibles and co-insurance payments as maternity benefits. The law also permits insurers to limit coverage to a lifetime maximum of $15,000. (Arkansas Statutes Annotated, Sections 23-85-137 and 23-86-118).
The California law requires certain insurers to offer coverage for infertility diagnosis and treatment. That means group health insurers covering hospital, medical or surgical expenses must let employers know infertility coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their employee insurance plans.
The law specifically exempts insurers from having to offer in vitro fertilization coverage. Also, the law does not require employers that are religious organizations to offer coverage for treatment that conflicts with the organization's religious and ethical purposes. (California Health and Safety Code, Section 1374.55).
Mandates insurance carriers to offer group policyholders coverage of infertility treatment, excluding IVF but including GIFT. (Group health insurers covering hospital, medical or surgical expenses must let employers know infertility coverage is available.)
Cal. Health & Safety Code § 1374.55 requires health care service plan contracts that cover hospital, medical, or surgical expenses on a group basis to offer coverage for the treatment of infertility, except in vitro fertilization. The law requires every plan to communicate the availability of coverage to policyholders. The law defines infertility, treatment for infertility and in vitro fertilization. The laws clarifies that religious employers are not required to offer coverage for forms of treatment that are inconsistent with the organization's religious and ethical principles.
Cal. Insurance Code § 10119.6 (1989) requires insurers to offer coverage of infertility treatments, except for in vitro fertilization. Infertility, in this case, may be a result of a medical condition or may refer to the inability to carry a pregnancy during a one-year or more period of time. Infertility treatment refers to diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer.
Conn. Public Act No. 05-196 Concerns health insurance benefits for the diagnosis and treatment of infertility; requires health insurance policies to provide coverage for medically necessary expenses of the diagnosis and treatment of infertility except where such coverage is contrary to the religious beliefs of an employer or individual.
Conn. Gen. Stat. § 38a-536 (1989) requires that health insurance organizations offer coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including in vitro fertilization procedures. Infertility, in this case, refers to an otherwise healthy individual's inability to retain a pregnancy during a one-year period.
Individual and group health insurance policies are required to cover medically necessary expenses for infertility diagnosis and treatment. Infertility is defined as the inability to conceive or sustain a successful pregnancy during a one-year period.
Covered treatments include ovulation induction, interuterine insemination, IVF, uterine embryo lavage, embryo transfer, GIFT, ZIFT, and low tubal embryo transfer. Coverage is limited to individuals who have maintained coverage under the policy for at least a year.
Individuals seeking coverage must disclose to their insurance carrier any prior infertility treatments for which they received coverage under a different insurance policy. Religious employers are permitted to exclude coverage for treatments that are contrary to their bona fide religious tenets. (Public Act No.05-196)
GA Admin. code 290-5-37-03 (1980) outlines what services must be covered in an HMO's basic insurance plan; states that the HMO may not place limitations on basic care or invoke waiting periods, coverage limitations, etc. States that an HMO may extend its basic coverage to include infertility treatments.
Hawaii Rev. Stat. §§ 431:10A-116.5 and 432.1-604 (2003, 1989) requires all accident and health insurance policies that provide pregnancy-related benefits to also include a one-time only benefit for outpatient expenses arising from in vitro fertilization procedures. In order to qualify for in vitro fertilization procedures, the couple must have a history of infertility for at least five years or prove that the infertility is a result specified medical conditions. [c 332, §2 and c 276, §4]
The Hawaii law requires certain insurance plans to provide a one-time only benefit for outpatient costs resulting from in vitro fertilization. Those plans include individual and group
health insurance plans, hospital contracts or medical service plan contracts that provide pregnancy-related benefits.
o Abnormal male factors contributing to the infertility. (Hawaii Revised Statutes, Sections 431-lOA-116.5 and 432.1-604).
Mandates insurance carriers that provide pregnancy–related benefits to cover the diagnosis and treatment of infertility, including various ART procedures, but limits first-time
attempts to four complete oocyte (egg) retrievals, and second births to two complete oocyte retrievals. Insurance carriers are not required to provide this benefit to businesses (group policies) of 25 or
Ill. Rev. Stat. ch. 215, § ILCS 5/356m (1991, 1997) requires certain insurance policies that provide pregnancy-related benefits to provide coverage for the diagnosis and treatment of infertility. Coverage includes in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer. [P.A. 89-669]
Mandates insurance carriers to cover the "diagnosis and treatment of correctable medical conditions." Thus, insurers may not deny coverage for treatment of a correctable medical condition to someone solely because the condition results in infertility. Coverage is not required for fertility drugs; in vitro fertilization or any other assisted reproductive technique; or reversal of tubal ligation, a vasectomy, or any other method of sterilization.
Mandates insurance carriers that provide pregnancy–related benefits to cover IVF after a two–year wait following diagnosis, with no wait required for certain diagnoses. Religious organizations can choose not to provide coverage based on their religious views.
Md. Insurance Code Ann. § 15-810 (2000) amends the original 1985 law and prohibits health insurers that provide pregnancy-related benefits from excluding benefits for all outpatient
expenses arising from in vitro fertilization procedures performed. The law clarifies the conditions under which services must be provided, including a history of infertility of at least 2 years' duration
and infertility associated with one of several listed medical conditions. An insurer may limit coverage to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit
of $100,000. The law clarifies that an insurer or employer may exclude the coverage if it conflicts with the religious beliefs and practices of a religious organization, on request of the religious organization.
Regulations that took effect in 1994 exempt businesses with 50 or fewer employees from having to provide the IVF coverage. [2000 Md. Laws, Chap. 283 (HB 350)]
The Maryland law requires health and hospital insurance policies that provide pregnancy-related benefits to also cover the outpatient costs of in-vitro fertilization. Policies that must provide the coverage include those covering people who live and work in the state, regardless of whether the policy is issued inside or outside the state. HMO's must provide IVF benefits to the same extent as the benefits provided for other infertility services.
Regulations that took effect in 1994 exempt businesses with 50 or fewer employees from having to provide the IVF coverage. (Maryland Insurance Article §15-810, Health General Article §19-706).
Mass. Gen. Laws Ann. ch. 175, § 47H, ch. 176A, § 8K, ch. 176B, § 4J, ch. 176G, § 4, and 211 CMR 37.00 (1987) requires general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits to also provide coverage for diagnosis and treatment of infertility, including in vitro fertilization. The law defines "infertility" as the condition of a presumably healthy individual who is unable to conceive or produce conception during a period of one year.
This state's law requires health maintenance organizations and insurance companies that cover pregnancy-related benefits to cover medically necessary expenses of infertility diagnosis and treatment. The law defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period."
Insurers may, but are not required, to cover experimental procedures, surrogacy, reversal of voluntary sterilization or cryopreservation of eggs. (Annotated Laws of Massachusetts, Chapters 175,§ 47H; 176A,§8K;176B,§4J; and l76G,§4, 211 CMR 37.00).
This state's law requires health maintenance organizations to cover infertility services as part of basic preventive health care services. The law does not define infertility or the scope of services covered; nor did the state ever draft regulations explaining what infertility services entail.
As for health insurers other than HMO's., the law specifically excludes infertility coverage from the required scope of health benefits those insurers must provide. (Montana Code Annotated, Sections 33-22-1521 and 33-31-102).
Mandates HMO's (but not other types of insurers) to cover infertility treatment as a basic health care service. The law does not define "infertility services", and some HMO's
Mont. Code Ann. § 33-22-1521 (1987) revises certain requirements of Montana's Comprehensive Health Association, the state's high-risk pool, and clarifies that covered expenses do not include charges for artificial insemination or treatment for infertility. (S.B. 310)
Mont. Code Ann. § 33-31-102(2)(v), et seq. (1987) requires health maintenance organizations to provide basic health services on a prepaid basis, which include infertility services. Other insurers are exempt from having to provide the coverage.
N.J. Laws, Chap. 236 (2001) requires health insurers to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility, including medications, surgery, in vitro fertilization, embryo transfer, artificial insemination, gamete intra fallopian transfer, zygote intra fallopian transfer, intracytoplasmic sperm injection and four completed egg retrievals per lifetime of the covered person. The law includes some restrictions as well as a religious exemption for employers that provide health coverage to less than 50 employees. (SB 1076)
The Family Building Act requires insurance policies that cover more than 50 people and provide pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility. The law defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex (female partner under the age of 35) or one year of unprotected sex (female partner over the age of 35) or the inability to carry a pregnancy to term.
The law allows religious organizations to request an exclusion of this coverage if it is contrary to the religious employer's bona fide religious tenets.
Insurers are required to cover the diagnosis and treatment of correctable medical conditions and shall not exclude coverage of a condition solely because the medical condition results in infertility. Private, group health insurance plans, issued or delivered in the state of New York providing coverage for hospital care or surgical and medical care are required to provide coverage for the diagnosis and treatment of infertility for patients between the ages of 21 and 44, who have been covered under the policy for at least 12 months. Certain procedures are excluded from this requirement, including IVF, GIFT, ZIFT, reversal of elective sterilization, sex change procedures, cloning, and experimental procedures. Plans that include coverage for prescription drugs must include coverage of drugs approved by FDA for use in diagnosis and treatment of infertility. (New York Consolidated Laws, Insurance, Section 3221(k)(6), Section 4303(s).)
N.Y. Insurance Law §§ 3216 (13), 3221 (6) and 4303 (1990) prohibits individual and group health insurance policies from excluding coverage for hospital care, surgical care and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility. The law does not require coverage for in vitro fertilization.
Ohio's law requires health maintenance organizations to cover basic preventive health services, including infertility The Ohio Insurance Department has no written definition of infertility services, but states that the procedure must be medically necessary. Experimental procedures are not covered. (Ohio Revised Code Annotated §1751)
Ohio Rev. Code Ann. § 1751.01 (A) (7) (1991) requires insurers to offer "basic health care services," which include infertility services, when medically necessary.
Mandates HMO's. (but not other types of insurers) to cover infertility treatment as a "preventative" benefit. The treatment must be "medically necessary," and the Ohio Department of
Insurance has ruled that GIFT, ZIFT and IVF are not medically necessary.
R.I. Gen. Laws §§ 27-18-30, 27-19-23, 27-20-20 and 27-41-33 (1989) requires any contract, plan or policy of health insurance (individual and group), nonprofit hospital service, nonprofit medical service and health maintenance organization to provide coverage for medically necessary expenses of diagnosis and treatment of infertility. The law clarifies that the co-payments for infertility services not exceed 20 percent. Infertility is defined as the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year. Rhode Island includes IVF coverage.
This state's law requires certain insurers that cover pregnancy services to offer coverage for in vitro fertilization. That means insurers must let employers know this coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their health plans.
The law does not require organizations that are affiliated with religious groups to cover treatment that conflicts with the organization's religious and ethical beliefs. (Texas Insurance Code, Article 3.51-6).
Tex. Insurance Code Ann. § 3.51-6, Sec. 3A (1987) requires that all health insurers offer and make available coverage for services and benefits on an expense incurred or prepaid basis for outpatient expenses that may arise from in vitro fertilization procedures. In order to qualify for in vitro fertilization services, the couple must have a history of infertility for at least five years or have specified medical conditions resulting in infertility.
West Virginia's law requires health maintenance organizations to cover basic health care services, including infertility services, when medically necessary. The West Virginia Insurance Commissioner does not define infertility services (West Virginia Code §33-25A-2) and HMO's have interpreted the term as excluding IVF.
W. Va. Code § 33-25A-2 (1995) amends the 1997 law and requires health insurers to cover "basic health care services," which include infertility services. Applies to HMO's. only.
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