Topic:
MEDICAL CARE; PREGNANCY; HEALTH INSURANCE;
Location:
INSURANCE - HEALTH - MANDATES;

OLR Research Report


March 1, 2005

 

2005-R-0236

INSURANCE COVERAGE FOR INFERTILITY TREATMENT

By: Janet L. Kaminski, Associate Legislative Attorney

You asked for infertility treatment coverage requirements in those states that mandate such coverage.

SUMMARY

Fourteen states require insurers to either (1) offer infertility treatment coverage to group health plan sponsors or (2) provide coverage in group and individual plans. Five states require the offer of coverage (California, Connecticut, Ohio, Texas, and West Virginia). Nine states mandate coverage for infertility treatment (Arkansas, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, and Rhode Island).

The services and treatments these states require vary considerably, as does the definition of “infertility.” Only two states permit lifetime benefit maximums: Arkansas (not less than $15,000) and Maryland (not to exceed $100,000).

For a discussion of infertility causes and treatments and whether it is a disability under the Americans with Disabilities Act, see OLR Report 2005-R-0145 (copy enclosed).

OFFER OF COVERAGE

California

Insurers and HMOs must offer group plans coverage for infertility treatment, except in vitro fertilization (IVF), under terms and conditions agreed upon between the group plan sponsor and the carrier.

“Infertility” is either (1) the presence of a condition known to cause infertility or (2) the inability to conceive or carry a pregnancy to live birth after one year or more of regular sexual relations without contraception. “Treatment for infertility” includes diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer (GIFT).

Any employer, insurer, or HMO that is affiliated with a religious organization is not required to offer infertility treatment coverage if it is inconsistent with its religious and ethical principles (Cal. Ins. Code 10119.6 and Cal. Health & Safety Code 1374.55).

Connecticut

Insurance companies must offer group plans coverage for the medically necessary expenses for the diagnosis and treatment of infertility, including IVF. “Infertility” is the condition of a presumably healthy individual who is unable to conceive, produce conception, or retain a pregnancy during a one-year period (CGS 38a-536).

Ohio

Insurers must offer coverage for medically necessary “basic health care services,” which includes preventive health care services. “Preventive health care services” include voluntary family planning services, infertility services, periodic physicals, prenatal obstetrical care, and well-child care (Ohio Rev. Code 1751.01).

Texas

Insurers and HMOs must offer group plans coverage for services and benefits for outpatient expenses that arise from IVF procedures if the plans provide pregnancy-related benefits. IVF benefits must be provided to the same extent as benefits provided for pregnancy-related procedures.

To be eligible for the offered coverage, several requirements must be met. The fertilization attempt must be made only with the patient's spouse's sperm. The infertility must have lasted at least five continuous years or is associated with one or more of the following conditions: (1) endometriosis, (2) exposure in utero to diethylstilbestrol (DES), (3) blockage or surgical removal of one or both fallopian tubes, or (4) oligospermia (deficient sperm count). The patient must have been unable to attain a successful pregnancy through any less costly applicable infertility treatment for which coverage is available under the plan. Lastly, the IVF procedure must be performed at a medical facility that conforms to the American College of Obstetric and Gynecology (ACOG) guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs.

An insurer or HMO directly affiliated with a bona fide religious denomination that holds IVF as contrary to moral principals held essential to its beliefs is exempt from offering IVF coverage (Tex. Ins. Code Ann. 3.51-6, Sec. 3A).

West Virginia

HMOs must offer coverage for “basic health care services,” which includes infertility services (W. Va. Code 33-25A-2).

MANDATED COVERAGE

Arkansas

Insurers must cover IVF, per coverage levels set by the insurance commissioner. Coverage includes services performed at a medical facility that conforms to ACOG guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs (Ark. Code Ann. 23-85-137).

Coverage must be provided when several requirements are met. The fertilization attempt must be made with the patient's spouse's sperm. The couple had unexplained infertility for at least two years or the infertility is associated with one or more of the following conditions: (1) endometriosis, (2) exposure in utero to DES, (3) blockage or surgical removal of one or both fallopian tubes but not a result of voluntary sterilization, or (4) abnormal male factors contributing to the infertility. The patient must have been unable to attain a successful pregnancy through any less costly applicable infertility treatment for which coverage is available under the policy. Lastly, the IVF procedure must be performed at a medical facility licensed or certified by the Arkansas Department of Health that conforms to ACOG guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs (Ark. Reg. 054 00 001, 5).

IVF benefits must be the same as the benefits provided for maternity and may be subject to the same deductibles, co-insurance, and out-of-pocket limitations. Any pre-existing condition limitation must not exceed 12 months. A lifetime maximum benefit of not less than $15,000 may be provided. Other infertility treatments may be included in addition to IVF. Cryopreservation, the procedure whereby embryos are frozen for later implantation, must be included in the IVF benefit (Ark. Reg. 054 00 001 6 – 8).

Hawaii

Individual and group health insurance policies that provide pregnancy-related benefits must include, in addition to any other infertility treatment benefits, a one-time only benefit for outpatient expenses arising from IVF. IVF benefits must be provided to the same extent as those provided for pregnancy.

In addition, the fertilization attempt must be made only with the patient's spouse's sperm. The infertility must have lasted at least five continuous years or is associated with one or more of the following conditions: (1) endometriosis, (2) exposure in utero to DES, (3) blockage or surgical removal of one or both fallopian tubes, or (4) abnormal male factors contributing to the infertility. The patient must have been unable to attain a successful pregnancy through any less costly infertility treatment for which coverage is available under the policy. Lastly, the IVF procedure must be performed at a medical facility that conforms to ACOG guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs (Haw. Rev. Stat. 431:10A-116.5).

Illinois

Group insurance policies providing coverage for more than 25 employees that include pregnancy-related benefits must include coverage for the diagnosis and treatment of infertility, including IVF, uterine embryo lavage, embryo transfer, artificial insemination, GIFT, zygote intrafallopian transfer (ZIFT), and low tubal ovum transfer. “Infertility” means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.

Coverage for IVF, GIFT, or ZIFT is required only if (1) the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, medically-appropriate infertility treatments for which coverage is available under the policy; (2) the patient has not undergone four completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals must be covered; and (3) the procedures are performed at medical facilities that conform to ACOG guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs. The infertility coverage need not be included in a policy issued to or by a religious institution that finds the procedures to violate its religious and moral teachings and beliefs (215 Ill. Comp. Stat. 5/356m).

Maryland

Insurers and HMOs that provide plans to individuals or groups that include pregnancy-related benefits must also include benefits for outpatient expenses arising from IVF procedures. Insurers must provide IVF benefits to the same extent as those for pregnancy-related procedures. HMOs must provide IVF benefits to the same extent as those for other infertility services.

In addition, the fertilization attempt must be made with the patient's spouse's sperm. The infertility must have lasted at least two years or is associated with one or more of the following conditions: (1) endometriosis; (2) exposure in utero to DES; (3) blockage or surgical removal of one or both fallopian tubes; or (4) abnormal male factors, including oligospermia, contributing to the infertility. The patient must have been unable to attain a successful pregnancy through any less costly infertility treatment for which coverage is available under the policy. Lastly, the IVF procedure must be performed at a medical facility that conforms to ACOG guidelines for IVF clinics or to the American Fertility Society minimal standards for IVF programs.

Coverage may be limited to three IVF attempts per live birth, not to exceed a maximum lifetime benefit of $100,000. If coverage conflicts with bona fide religious beliefs and practices, a religious organization may request that the coverage be excluded (Md. Code Ann. Ins. 15-810).

Massachusetts

Insurance and HMO plans that include pregnancy-related benefits must provide, to the same extent that benefits are provided for pregnancy-related procedures, coverage for medically necessary expenses for infertility diagnosis and treatment. “Infertility” is the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period (Mass. Gen. Laws Ann. ch. 175, 47H; ch. 176A, 8K; ch. 176B, 4J; and ch. 176G, 4).

Coverage requirements are further detailed in administrative regulations. Insurers and HMOs are required to provide benefits for all non-experimental infertility procedures, including (1) artificial insemination; (2) IVF and embryo placement; (3) GIFT; (4) ZIFT; (5) intracytoplasmic sperm injection; and (6) sperm, egg, or inseminated egg procurement and processing, and banking of sperm or inseminated eggs, to the extent such costs are not covered by the donor's insurer, if any. Insurers and HMOs are prohibited from imposing exclusions, limitations, or other restrictions on coverage for infertility-related prescription drugs that are any different from those imposed on other prescription drugs. Insurers and HMOs are not required to provide coverage for experimental infertility procedures, surrogacy, reversal of voluntary sterilization, or cryopreservation of eggs.

In addition, deductibles, copayments, coinsurance, benefit maximums, waiting periods, and other terms for mandated infertility benefits cannot differ from those imposed for other services. Pre-existing condition exclusions or waiting periods cannot be imposed for infertility benefits. Insurers and HMOs may establish reasonable eligibility requirements based upon the insured patient's medical history and reasonable provider contracting standards. Standards and guidelines developed by ACOG or the American Society for Reproductive Medicine may serve as a basis for the eligibility and contracting requirements (Mass. Regs. Code tit. 211, 37.00, et seq.).

Montana

HMOs are required to provide “basic health care services,” which include infertility services (Mont. Code Ann. 33-31-102).

New Jersey

A group health insurance policy issued to a group of more than 50 persons that includes pregnancy-related benefits must provide coverage for medically necessary expenses arising from the diagnosis and treatment of infertility. Infertility coverage must include diagnosis and diagnostic tests, medications, surgery, IVF, embryo transfer, artificial insemination, GIFT, ZIFT, intracytoplasmic sperm injection, and four completed egg retrievals per lifetime of the covered person. Coverage for IVF, GIFT, and ZIFT may be limited to a covered person who (1) has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; (2) has not reached the limit of four completed egg retrievals; and (3) is 45 years old or younger. A religious employer may exclude coverage for IVF, embryo transfer, artificial insemination, ZIFT, and intracytoplasmic sperm injection, if they are contrary to its bona fide religious tenets.

“Infertility” is the disease or condition that results in the abnormal function of the reproductive system such that a person cannot (1) impregnate another; (2) conceive after two years of unprotected intercourse if the female is under 35 years old, or one year of unprotected intercourse if she is 35 or older or one of the partners is medically sterile; or (3) carry a pregnancy to live birth. Benefits must be provided to the same extent as for pregnancy-related procedures, except that services must be performed at facilities that conform to ACOG or the American Society for Reproductive Medicine standards. Copayments, deductibles, and benefit limits that apply to other medical or surgical benefits also apply to infertility diagnosis and treatment (N.J. Stat. Ann. 17B:27-46.1x).

New York

Individual and group health insurance policies are prohibited from excluding coverage for hospital, surgical, and medical care for the diagnosis and treatment of correctable medical conditions otherwise covered under the policy solely because the condition results in infertility (N.Y. Ins. Law 3216(13), 3221(6), and 4303(s)).

Group health insurance policies must provide coverage for infertility diagnosis and treatment to people age 21 to 44 years. Coverage may be subject to copayments, coinsurance, and deductibles that are consistent with those established for other policy benefits. Coverage is limited to people covered under the policy for at least 12 months. Coverage may exclude IVF, GIFT, ZIFT, reversal of elective sterilizations, sex change procedures, cloning, and experimental procedures (N.Y. Ins. Law 3221(6) and 4303(s)).

Insurers must use standards and guidelines no less favorable than those adopted by the American Society for Reproductive Medicine in relation to the (1) diagnosis of infertility, (2) identification of experimental procedures, (3) required provider standards, and (4) determination of appropriate medical candidates by the treating physician (N.Y. Comp. Codes R. & Regs. tit. 11, 52.17(35)).

Rhode Island

All insurance and HMO plans that include pregnancy-related benefits must provide coverage for medically necessary infertility diagnosis and treatment. Copayments for infertility services cannot exceed 20%. “Infertility” is the condition of an otherwise presumably healthy married individual who is unable to conceive or produce conception during a one-year period (R.I. Gen. Laws 27-18-30, 27-19-23, 27-20-20, and 27-41-33).

JLK:ro