Infertility Insurance Coverage

Infertility Insurance Coverage

At present, only 15 states have laws regarding insurance coverage for infertility treatment. If you live in a state that does not have infertility treatment laws, inquire about regulations with your insurance company. Currently, there is no law requiring insurance coverage for infertility.

 

Arkansas Infertility Insurance Coverage

1987
Arkansas State Annotated
Sections 23-85-137  23-86-118

 

Definition of Infertility and Client Requirements

  • The client and her spouse should have at least a 2-year history of infertility that is unexplained OR the infertility must be related to at least one of the following:
  • DES exposure
  • Endometriosis
  • Surgically removed/blocked fallopian tubes (not related to voluntary sterilization)
  • Abnormal male factors that cause infertility
  • The client’s eggs must be fertilized with sperm from her spouse.
  • The client must be a policyholder or the spouse of the actual policyholder.
  • The client is not able to obtain successful pregnancy through any less costly treatments covered by insurance.

 

Coverage

  • Lifetime $15,000 maximum for coverage.
  • All individual or group insurance policies that offer maternity benefits must cover in vitro fertilization (IVF), with the exception of HMOs.
  • Limits pre-existing condition to only 12 months.
  • Benefits for IVF are subject to the same coinsurance, deductibles, and out-of-pocket limitations as under the provision for maternity benefits.
  • Includes cryopreservation.
  • IVF procedures must be conducted at a medical facility certified or licensed by the state and compliant with the American Society of Reproductive Medicine (ASRM) guidelines and American College of Obstetricians and Gynecologists’ (ACOG).
  • Insurers can choose to include other infertility treatments or procedures under the IVF benefit.
  • Exceptions – Employers who self-insure are exempt from these laws.

 

California Infertility Insurance Coverage

 

1989
 Cal. Health & Safety Code
 Section 1374.55
Cal. Insurance Code 
Section 10119.6

 

Definition of Infertility and Client Requirements

  • Infertility means the existence of a physician-recognized health condition that can cause infertility, inability to conceive a baby, or carry a pregnancy to live birth following 12 months or more of regular sexual intercourse without birth control.
  • Requires group insurers to offer infertility treatment coverage except for IVF. Employers can choose whether or not to uncooperative infertility coverage as part of the employee health benefit package.

 

Coverage

  • No coverage is necessary. Insurers are only required to offer: diagnostic testing, diagnosis, medication, surgery, and gamete intra-fallopian transfer (GIFT).
    Exception
  • Does not include IVF.
  • Only requires insurers to offer coverage.
  • Employers who are self-insured are exempt from these law requirements.
  • Does not require coverage by religious organizations.

 

Connecticut Infertility Insurance Coverage

 

Definition of Infertility and Client Requirements

  • Infertility means the condition of a healthy person who is not able to sustain a pregnancy or conceive after 12 months.
  • Individual or group insurers are required to offer infertility coverage to people under age 40 years.
  • Limits coverage to people who have kept coverage under one policy for at least one year.

 

Coverage

  • Lifetime maximum coverage of 3 cycles of intrauterine insemination.
  • Lifetime maximum coverage of 4 cycles of ovulation induction.
  • Lifetime maximum coverage of 2 cycles of IVF, ZIFT, GIFT, or low tubal ovum transfer, with not more than 2 embyos implanted per cycle. Each transfer or fertilization is considered 1 cycle toward the maximum allowed.
  • Limits coverage for IVF, ZIFT, GIFT, and low tubal ovum transfer to eprsons who are not able to sustain a successful pregnancy or conceive through a less expensive and medically viable infertility procedure or treatment, unless the person’s doctor deems that these treatments are not likely to be successful.
  • Requires infertility treatment or procedures to be done at medical centers that are associated with the American Society of Reproductive Medicine and the Society of Reproductive Endocrinology and Infertility Guidelines.
  • Exceptions – Does not require religious organization to offer coverage. Employers who are self-insured are exempt from these law requirements.

 

Hawaii Infertility Insurance Coverage

 

1989, 2003
 Hawaii Rev. Stat
 Sections 431:10A-116. 5
432.1-604

  • Definition of Infertility and Client Requirements
  • The client’s eggs must be fertilized with the spouse’s sperm.
  • Individual and group insurers must cover 1 cycle of IVF if a client or client’s spouse has at least a 5-year history of infertility, or the infertility is related to at least

 

1 of the following:

  • DES exposure
  • Endometriosis
  • Blosed/surgically removed fallopian tubes
  • Abnormal male factors that contribute to infertility
  • Coverage is offered when the client has not been able to obtain successful pregnancy through other infertility treatment covered by insurance.

 

Coverage

  • 1 cycle of IVF.
  • The coverage msut be offered to the same extent as maternity benefits.
  • IVF procedures must be performed at medical centers that are associated with the American Society of Reproductive Medicine and the Society of Reproductive
  • Endocrinology and Infertility Guidelines.
  • Exceptions – Employers who are self-insured are exempt from the law requirements.

Illinois Infertility Insurance Coverage

 

1991, 1997, Ill Rev. Stat. ch 215
 Section ILCS 5/356m

 

Definition of Fertility and Client Requirements

  • Infertility means not being able to conceive after 12 months of unprotected sexual intercourse or the inability to maintain a successful pregnancy.

 

Coverage

  • Group insurers and HMOs that offer pregnancy-related coverage must provide treatment for infertility including, but not limited to: IVF, diagnosis of infertility, uterine embryo lavage, artificial insemination, embryo transfer, GIFT, ZIFT, and low tubal ovum transfer.
  • Coverage for GIFT, ZIFT, and IVF provided if the client is unable to attain or sustain a successful pregnancy through less costly, reasonable, infertility treatments covered by insurance.
  • Each client is covered up to 4 egg retrievals. However, if a live birth occurs, 2 additional egg retrievals will be covered, with a maxium for the lifetime of 6 retrieval coverage.
  • The procedures must be performed at healthcare facilities are associated with the American Society of Reproductive Medicine and the Society of Reproductive Endocrinology and Infertility Guidelines.
  • Exceptions – Does not require religious employers to cover treatment for infertility. Employers with less than 25 employees do not have to offer coverage.
    Employers who are self-insured are exempt from the law requirements.

 

Louisiana Infertility Insurance Coverage

 

2001 
Louisiana State Law 
Subsection 215.23, Acts 2001, No. 1045, subsection

 

Definition of Infertility and Client Requirements

  • Does not permit the exclusion of coverage for diagnosis and treatment of medical conditions soley because the condition results in infertility.
  • Exceptions – The law does not require insurers to cover drugs for fertility, IVF, or other assited reproductive techniques, as well as vasectomy, reversal of tubal ligation, or any other method of sterilization. Employers who are self-insured are exempt from law requirements.

 

 

Maryland Infertility Insurance Coverage

 

2000
 MD Insurance Code Ann. Section 15-810
MD Health General Code Ann. Section 19-701

 

Definition of Infertility and Client Requirements

  • The client’s eggs must be fertilized with her own spouse’s sperm.
  • The client is the policyholder or a covered person on the policy.
  • The client and spouse must have a history of 2 years infertility or the infertility must be associated with at least one of the following:

DES exposure

Endometrosis

Blocked/surgically removed fallopian tubes

Abnormal male factors that contribute to the infertility

The client’s eggs are fertilized with the spouse’s sperm.

The client is a policyholder or a covered person of the policyholder.

The client has not been able to become pregnant through less costly treatments.

Coverage

  • Lifetime maximum of $100,000.
  • Individual and group insurance policies that offer pregnancy-related benefits must cover the cost of 3 IVF cycles per live birth.
  • IVF procedure must be performed at clinics that are associated with the American Society of Reproductive Medicine and the Society of Reproductive
  • Endocrinology and Infertility Guidelines.
  • Exceptions – Employers with less than 50 employees do not have to provide coverage. Does not require religious employers to cover treatment of infertility. Employers who are self-insured are exempt from low requirements.

Massachusetts Infertility Insurance Coverage

 

1987, amended 2010
 Mass Gen Laws Ann. Ch. 175, Section 47H, ch. 176A, Section 8K, ch.176B, Section 4J, ch 176G, Section 4, and 211 CMR 37.00

 

Definition of Infertility and Client Requirements

  • Infertility is any condition where a person is unable to conceive or produce conception during a year if the woman is age 35 or younger, or during a 6 months if the female is over age 35 years. For purposes of meeting certain criteria for infertility, but is not able to carry the pregnancy to term, the period of time she attempted to conceive before achieving pregnancy shall be included in the 1-year or 6-month period.

 

Coverage

  • All insurers providing pregnancy-related benefits must provide the diagnosis of treatment of infertility including: IVF, GIFT, artificial insemination, sperm, egg, or/and inseminated egg procurement and processing, and banking of inseminated eggs or sperm, to the extent such costs are not covered by the insurer, ZIFT, ICSI, assisted hatching, or cryopreservation of eggs.
  • Insurers shall not impose any exclusions, restrictions, or limitations on coverage of infertility drugs that are different from any imposed on other prescription drugs, nor shall they impose copayments, deductibles, coinsurance, benefit maximums, waiting periods or any other limitations on coverage for required infertility benfits which are different from any imposed upon benefits for services unrelated to infertility.
  • The law does not limit the number of treatments cycles and does not have a lifetime cap amount. Insurers may set limites based on clients’ medical histories and guidelines.
  • Exceptions – Employers who self-insure are exempt from law requirements. Insurers are not requried to cover experimental procedures, surrogacy, or voluntary sterilization reversal.

 

 

Montana Infertility Insurance Coverage

 

1987
 Mont. Code Ann. Section 33-22-1521
 Section 33-31-102(2)(v)

 

Definition of Infertility and Client Requirements

  • Infertility is not defined in regulation or law.

 

Coverage

  • Requires HMOs to cover certain infertility services as part of their basic healthcare services.
  • Exceptions – Employers who are self-insured are exempt from law requrirements.

 

New Jersey Infertility Insurance Coverage

 

2001 
NJ Laws, Chap. 236

 

Definition of Infertility and Client Requirements

  • Infertility means a condition or disease that results in abnormal function of the reproductive system where a male is unable to get a female pregnant, a female 35 years of age and younger cannot conceive after 2 years of unprotected sexual intercourse, a female 35 years of age and older is not able to conceive after 1 year of unprotected sexual intercourse, the female or male is medically sterile, or the female cannot carry the pregnancy to term.
  • Must be age 46 years or younger.
  • Infertility does not apply to a person who has been voluntarily sterilized.
  • The client has been unable to obtain successful pregnancy through any less costly treatments covered by the insurance plan.

 

Coverage

Group insurers that provide pregnancy-related coverage must offer infertility treatment including:

  • Assisted hatching
  • Assisted insemination
  • Diagnosis and diagnostic testing
  • Fresh or frozen embyro transfers
  • 4 complete egg retrieval procedures per lifetime.
  • ICSI
  • IVF
  • IVF with donor eggs
  • Gestational carrier or surrogate
  • GIFT
  • ZIFT
  • Medications
  • Surgery and microsurgical sperm aspiration
  • Ovulation induction
  • Exceptions – Cryoperservation is not covered, Employers with less than 50 employees do not have to provide coverage. Infertility treatments cannot be experimental or investigational. Nonmedical costs of egg or sperm donor are not covered. Does not require religious employers to cover infertility treatments.

 

 

New York Infertility Insurance Coverage

 

1990, 2002
 NY S.B. 6257-B/A.B. 9759-B
NY Insurance Law Sections 3216 (13), 3221

 

Definition of Infertility and Client Requirements

  • The law abides by ASRM definition of infertility, which is inability to achieve pregnancy after 1 year of unprotected sexual intercourse if you are 35 years of age and younger, and after 6 months if you are over 35.
  • Prohibits exclusion of coverage for the diagnosis and treatment of a correctable health problem, solely based on the fact the condition is related to infertility.
  • Coverage is provided to patients 21-44 years of age.
  • Clients should be covered under their insurance policy for at least 12 months before receiving coverage for infertility.

 

Coverage

Group policies should provide diagnostic tests and procedures including:

  • Endometrial biopsy
  • Hysterosalpingogram
  • Hysteroscopy
  • Sono-hysterogram
  • Laparoscopy
  • Post coital tests
  • Testis biopsy
  • Semen analysis
  • Blood tests
  • Ultrasound
  • Every policy that provides prescription drug coverage should also include FDA-approved drugs for use in the diagnosis and treatment of infertility.
  • Exceptions – Employers who are self-insured are exempt from law requirements. Excludes coverage for GIFT, IVF, ZIFT, sex change procedures, reversal of elective sterilizations, cloning, or experimental medical/surgical procedures.

 

 

Ohio Infertility Insurance Coverage

 

1991
 Ohio Rev. Code Ann. Section 1751.01(A)(7)
Coverage

  • Requires HMOs to cover basic healthcare services, such as infertility treatment when medically necessary.
  • Diagnostic and exploratory procedures are covered, such as surgical procedures to correct medically diagnosed conditions or diseases of the reproductive organs, such as endometriosis, testicular failure, and collapsed/blocked fallopain tubes.
  • GIFT, IVF, and ZIFT are covered but not required by law.
  • Exemptions – Employers who are self-insured are exempt from law requirements.

 

 

Rhode Island Infertility Insurance Coverage

 

1989
 RI Gen. Laws sections 27-18-30, 27-19-23, 27-20-20, and 27-41-33
Revised 2006

 

Definition of Infertility and Client Requirements

Infertility means the condition of a healthy married person who is not able to conceive or produce conception during a 2-year timeframe.

 

Coverage

  • Coverage is offered for women ages 25-40 years of age.
  • Insurers that cover pregnancy benefits must offer coverage for medically necessary expenses of infertility diagnosis and treatment.
  • The law imposes a $100,000 cap on treatment.
  • The insurer can impose up to a 20% co-pay.
  • Exceptions – Self-insured employers are exempt from the law requirements.

 

Texas Infertility Insurance Coverage

 

1987
 Tex. Insurance Code Ann. Section 3.51-6, Sec. 3A

 

Definition of Infertility and Client Requirements

  • Requires group insurers to offer coverage for IVF. Employers can choose whether to or not include infertility coverage as part of the employee benefits.
  • If an employee offers infertility treamtent, clients must meet the following:
  • Client for IVF is a policyholder or spouse of such.
  • The client’s eggs must be fertilized by sperm from spouse.
  • The client and spouse have a historyh of infertilitiy of at least 5 years continuous, or have infertility associated with endometriosis, DES exposure, or blockage/surgical removal of 2 or both fallopain tubes.
  • The client has been unable to get pregnant through less costly treatments.
  • The client has IVF procedures performed at the healthcare facility that is associated with ACOG and ASRM guidelines.

 

Coverage

  • No coverage is required. Insurers are only required to offer IVF.
  • Exceptions – Does not require religious employers to cover infertility treatment. Employers who self-insure are exempt from the requirements of the law.

 

 

West Virginia Infertility Insurance Coverage

 

1995
 W.Va. Code Section 33-25A-2

 

Definition of Infertility and Client Requirements

  • The law does not define “infertility.”

 

Coverage

  • Requires HMOs to cover infertility services under “basic health care services.”
  • Exception – Employers who self-insure are exempt from the requirements of the law.