States Mandating Insurance Coverage for Infertility and Pregnancy Loss

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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).

 

Maryland

The Maryland law requires health and hospital insurance policies that provide pregnancy benefits to also cover the cost of in-vitro fertilization. However, the law does not apply to health maintenance organizations, or HMOs. Policies that must provide the coverage include those covering people who live and work in the state, regardless of whether the policy is issued in or outside the state.

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 is unable to get pregnant through less expensive covered treatments;
  • The IVF is performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
  • The patient and his or her spouse must have at least a five-year history of infertility;
  • OR their infertility must be associated with one or more of the following conditions:
    • Endometriosis;
    • Fetal exposure to diethylstilbestrol, also known as DES; or
    • Blocked or surgically removed fallopian tubes.

 

Regulations that took effect in 1994 exempt businesses with 50 or fewer employers from having to provide the IVF coverage.

(Annotated Code of Maryland, Article 48A, Sections 354DD, 470W and 477EE).

 

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 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).

 

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).

 

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