inciid
glossary | contact us | forums site search
Home The InterNational Council on Infertility Information Dissemination, Inc.
Title Image
HOME » Insurance: Programs & Mandates

States mandating infertility insurance coverage

Last Updated: November 9, 2004
Page: 1


| Arkansas | California |Connecticut |
| Hawaii | Illinois | Maryland |

| Massachusetts| Montana | New York |
| New Jersey | Ohio | Rhode Island |
|Texas | West Virginia |
| National IVF Scholarships |

Arkansas

This law requires all health insurers that cover maternity benefits to cover the cost of in vitro fertilization (IVF) Health maintenance organizations, commonly called HMOs, are exempt from the law. Patients need to meet the following conditions in order to get their IVF covered: The patient must be the policyholder or the spouse of the policyholder and be covered by the policy; The patient's eggs must be fertilized with her spouse's sperm; The patient and her spouse must have at least a two-year history of unexplained infertility OR the infertility must be associated with one or more of the following conditions Endometriosis; Fetal exposure to diethylstilbestrol, also known as DES; Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization; or Abnormal male factors contributing to the infertility.

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).

California

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. 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 defines infertility as:
* The presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility; or
* The inability to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of sexual relations without contraception.

The law defines treatment as including, but not limited to:
* Diagnosis and diagnostic tests;
* Medication;
* Surgery; and
* Gamete Intrafallopian Transfer, also known as GIFT.

The law specifically exempts insurers from having to provide 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).

Connecticut

Summary (Oct 2005)

The Act defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a oneyear period". The Act provides that covered medically necessary expenses of the diagnosis and treatment of infertility include, but are not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer.

The Act specifies permissible policy limitations, maximums and requirements as follows:

(1) Limit such coverage to an individual until the date of such individual's fortieth birthday;
(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles
(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;
(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intrafallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;
(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who

Hawaii

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.

Patients need to meet the following conditions in order to get their IVF covered:
* The patient's eggs must be fertilized with the sperm of the patient's spouse
* The patient or the patient's spouse must have at least a five-year history of infertility;
* The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
* The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
* The infertility must be associated with one or more of the following conditions:
+ Endometriosis;
+ Fetal exposure to diethylstilbestrol, also known as DES;
+ Blocked or surgically removed fallopian tubes; or
+ Abnormal male factors contributing to the infertility.

(Hawaii Revised Statutes, Sections 431-lOA-116.5 and 432.1-604).

Illinois

This law requires insurance policies that cover more than 25 people to cover costs of the diagnosis and treatment of infertility. The law defines infertility as the inability to get pregnant after one year of unprotected sex or the inability to carry a pregnancy.

Coverage includes, but is not limited to:
* In vitro fertilization (IVF); Uterine embryo lavage; Embryo transfer;
* Artificial insemination;
* Gamete intrafallopian transfer (GIFT);
* Zygote intrafallopian transfer (ZIFT);
* Intracytoplasmic Sperm Injection (ICSI);
* Four completed egg retrievals per lifetime; and
* Low tubal egg transfer.

Coverage for IVF, GIFT and ZIFT is required only if:
* The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;
* The patient has not reached the maximum number of allowed egg retrievals;
* The procedures are performed at facilities that conform to standards set by the America Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

The law exempts religious organizations which believe the covered procedures violate their teachings and beliefs.

(Illinois Compiled Statutes Annotated, Chapter 215, Sections 5/356m and 125/5-3).

Maryland

Updated 7/20/06 per Maryland Insurance Administration

Maryland's law changed in 2000. The law does apply to health maintenance organizations, but it only applies to policies issued in Maryland. It will not apply to residents of Maryland covered under a policy issued in another state. Here is the text of the current law:

(a) This section applies to:

(1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

(b)

(1) An entity subject to this section that provides pregnancy-related benefits may not exclude benefits for all outpatient expenses arising from in vitro fertilization procedures performed on the policyholder or subscriber or dependent spouse of the policyholder or subscriber.
(2) The benefits under this subsection shall be provided:

(i) for insurers and nonprofit health service plans, to the same extent as the benefits provided for other pregnancy-related procedures; and
(ii) for health maintenance organizations, to the same extent as the benefits provided for other infertility services.

(c) Subsection (b) of this section applies if:

(1) the patient is the policyholder or subscriber or a covered dependent of the policyholder or subscriber;
(2) the patient's oocytes are fertilized with the patient's spouse's sperm;
(3) (i) the patient and the patient's spouse have a history of infertility of at least 2 years' duration; or
(ii) the infertility is associated with any of the following medical conditions:

1. endometriosis;
2. exposure in utero to diethylstilbestrol, commonly known as DES;
3. blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or
4. abnormal male factors, including oligospermia, contributing to the infertility;


(4) the patient has been unable to attain a successful pregnancy through a less costly infertility treatment for which coverage is available under the policy or contract; and
(5) the in vitro fertilization procedures are performed at medical facilities that conform to the American College of Obstetricians and Gynecologists guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.

(d) An entity subject to this section may limit coverage of the benefits required under this section to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000.

(e) Notwithstanding any other provision of this section, if the coverage required under this section conflicts with the bona fide religious beliefs and practices of a religious organization, on request of the religious organization, an entity subject to this section shall exclude the coverage otherwise required under this section in a policy or contract with the religious organization.

Massachusetts

This state's law requires health maintenance organizations and insurers 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."

Benefits covered include:
* Artificial insemination;
* In vitro fertilization;
* Gamete Intrafallopian Transfer;
* Sperm, egg and/or inseminated egg retrieval, to that extent that those costs are not covered by the donor's insurer;
* Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility; and
* Zygote Intrafallopian Transfer (ZIFT).

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).

Montana

This state's law requires health maintenance organizations (Blue Cross Blue Shield is the only one in Montana) 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 HMOs, 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)

New Jersey        

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. 

Coverage includes, but is not limited to: 

  • Diagnosis & diagnostic tests
  • Medications
  • Surgery
  • In vitro fertilization (IVF)
  • Embryo transfer
  • Artificial insemination
  • Gamete intra fallopian transfer (GIFT)
  • Zygote intra fallopian transfer (ZIFT)
  • Intracytoplasmic Sperm Injection (ICSI)
  • Four completed egg retrievals per lifetime

Coverage for IVF, GIFT and ZIFT is required only if:

  • The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;
  • The patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger.
  • The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

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. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48E-35.22 Health Service Corporations; 26:2J-4.23 Health Maintenance Organizations)

New York

The New York law requires insurers to cover the diagnosis and treatment of correctable medical conditions and makes clear that coverage cannot be withheld for a correctable condition solely because the condition results in infertility.

However, the law DOES NOT require coverage for the reversal of voluntary sterilization, experimental procedures, or procedures intended solely to produce pregnancy - like IVF.

(New York Consolidated Laws, Insurance, Sections 3216, 3221 and 4303).
New York does have an IVF grant program for state residents.

Ohio

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 the following general interpretation is applied to the code:

Up to $2,000 worth of infertility services are to be covered if the couple experiences an inability to conceive purely as a result of infertility problems (unexplained infertility, for example). The $2,000 cap is not applied if another condition or medically related problem (endometriosis, for example) is involved. Experimental procedures - determined on a case-by-case basis by the Insurance Department --are not covered.

(Ohio Revised Code Annotated, Chapter 1742).

Rhode Island

The Rhode Island law requires insurers that cover pregnancy services to cover the cost of medically necessary expenses of diagnosis and treatment of infertility.

The law defines infertility as "the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year."

The patient's co-payment cannot exceed 20 percent (Rhode Island General Laws @ 27-18-30, 27-19-23, 27-20-20 and 27-41-33).

Texas

This state's law requires certain insurers that cover pregnancy services to offer coverage for infertility diagnosis and treatment - including in vitro fertilization. Therefore 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.

Patients need to meet the following conditions in order to get their IVF covered:
* The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
* The patient's eggs must be fertilized with her spouse's sperm;
* The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
* The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
* The patient and her spouse must have at least a continuous five-year history of unexplained infertility,
* OR the infertility must be associated with one or more of the following conditions:
+ Endometriosis.
+ Fetal exposure to diethylstilbestrol (DES);
+ Blocked or surgical removal of one or both fallopian tubes; or
+ Oligospermia

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).

West Virginia

Mandates HMOs to cover infertility treatment as a preventative benefit. The law does not define "infertility treatment" and HMOs have interpreted the term as excluding IVF.

Please email us if you have questions or if you have found errors in this data. Thanks!



[Print Version] [Send to Friend]





 
© 1992-2008 INCIID
PO Box 6836 Arlington, VA 22206
P:703.379.9178   F:703.379.1593
Contact Us
inciid INCIID Information Forums Chat Studies Calendar Shop 24 database queries total
Execution time = 0.334036 seconds
Cached: No