Mandate All Insurance to Cover Infertility as Basic Healthcare.

Currently only 15 states have laws requiring insurance coverage for infertility treatment.

1. Arkansas


2. Louisiana


3. New York


4. California


5. Maryland


6. Ohio


7. Connecticut


8. Massachusetts


9. Rhode Island


10. Hawaii


11. Montana


12. Texas


13. Illinois


14. New Jersey


15. West Virginia

If you live or work in a state that has an infertility coverage law in place, you should:

Click on the state name above for a summary of the law, and get the full text from your state legislative website.

Learn whether your employer plan is fully insured or self insured. Fully insured plans follow state law. Self insured plans follow federal law and are exempt from state law.

Learn if your employer plan is a "greater than 25" plan, "greater than 50" plan, etc. In this cases, employers with fewer than a set number of employees do not have to provide coverage.

Learn if your employer's policy was written in the goverened state. Generally, the policy must be written and/or reside in the state that has an infertility coverage law.

Learn if your employer offers more than one plan. If so, investigate which are fully insured plans in the state with an infertility coverage law.

For complete information on insurance coverage for employees, follow this link.

http://www.resolve.org/family-building-options/insurance_coverage/coverage-at-work.html

If the state you live in is not in the above list, there is no law in your state requiring insurance coverage for infertility treatment. http://www.contactingthecongress.org/

Contact your local representative and ask them to introduce legislation to require infertility treatment coverage.

ARKANSAS 1987
Ark. Stat. Ann
Sections 23-85-137
23-86-118

Definiton of Infertility/Patient Requirements

• The patient and her spouse must have at least a 2-year history of unexplained infertility OR the infertility must be associated with at least one of the following: endometriosis; DES exposure; blocked or surgically removed fallopian tubes that are not the result of voluntary sterilization; abnormal male factors contributing to the infertility.


• 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 obtain successful pregnancy through any less costly infertility treatments covered by insurance.

Coverage

• All individual and group insurance policies that provide maternity benefits must cover in vitro fertilization (IVF). HMO’s are exempt from the law.


• Lifetime maximum of $15,000 for coverage.


• IVF procedures must be performed at a facility licensed or certified by the state and conform to the American College of Obstetricians and Gynecologists’ (ACOG) and the American Society of Reproductive Medicine (ASRM) guidelines.


• Limits preexisting condition to 12 months.


• Includes cryoperservation as an IVF procedure.


• The benefits for IVF shall be subject to the same deductibles, coinsurance and out-of-pocket limitations as under maternity benefit provisions.


• Insurers may choose to include other infertility procedures or treatments under the IVF benefit.

Exceptions

• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• Requires group insurers to offer coverage of infertility treatment, except IVF. Employers may choose whether or not to include infertility coverage as part of their employee health benefit package.


• Infertility means the presence of a demonstrated condition recognized by a physicians 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 regular sexual relations without contraception.

Coverage

• No coverage is required. Insurers are only required to offer the following services. Employers decide if they will provide the following benefits to their employees: diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT).

Exceptions

• Only requires insurers to offer coverage.


• Does not include IVF.


• Does not require religious organizations to offer coverage.


• Employers who self-insure are exempt from the requirements of the law.

CONNECTICUT 2005

(For additional information on the Connecticut law, see CT Department of Insurance Bulletin)

Definition of Infertility/Patient Requirements

• Individual and group insurers are required to provide infertility coverage to individuals under 40 years old.


• Infertility means the condition of a presumably healthy individual who is unable to conceive or sustain a successful pregnancy during a one-year period.


• Limits coverage to individuals who have maintained coverage under a policy for at least 12 months.

Coverage

• Lifetime maximum coverage of 4 cycles of ovulation induction.


• Lifetime maximum coverage of 3 cycles of intrauterine insemination.


• Lifetime maximum coverage of 2 cycles of IVF, GIFT, ZIFT or low tubal ovum transfer, with not more than 2 embryo implantations per cycle. Each fertilization or transfer is credited as one cycle towards the maximum.


• Limits coverage for IVF, GIFT, ZIFT and low tubal ovum transfer to individuals who have been unable to conceive or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures, unless the individual’s physician determines that those treatments are likely to be unsuccessful.


• Requires infertility treatment or procedures to be performed at facilities that conform to the American Society of Reproductive Medicine and the Society of Reproductive Endocrinology and Infertility Guidelines.

Exceptions

• Does not require religious organizations to offer coverage.


• Employers who self-insure are exempt from the requirements of the law.

HAWAII 1989, 2003

Hawaii Rev. State Sections 431:10A-116.5 432.1-604

Definition of Infertility/Patient Requirements

• Individual and group insurers are required to cover one cycle of IVF if a patient or patient’s spouse has at least a 5 year history of infertility or the infertility is associated with at least one of the following conditions: endometriosis; DES exposure; blocked or surgically removed fallopian tubes; abnormal male factors contributing to the infertility.


• The patient’s eggs must be fertilized with her spouse’s sperm.


• Coverage is provided if the patient has been unable to obtain successful pregnancy through other infertility treatments covered by insurance.

Coverage

• One cycle of IVF.


• The coverage shall be provided to the same extent as maternity-related benefits.


• The IVF procedures must be performed at medical facilities that conform to ACOG and ASRM guidelines.

Exceptions

• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Fertility/Patient Requirements

• Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.

Coverage

• Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to: diagnosis of infertility; IVF; uterine embryo lavage; embryo transfer; artificial insemination; GIFT; ZIFT; low tubal ovum transfer.


• Coverage for IVF, GIFT and ZIFT is provided if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, infertility treatments covered by insurance.


• Each patient is covered for up to 4 egg retrievals. However, if a live birth occurs, two additional egg retrievals will be covered, with a lifetime maximum of six retrievals covered.


• The procedures must be performed at facilities that conform with ACOG and ASRM guidelines.

Exceptions

• Employers with fewer than 25 employees do not have to provide coverage.


• Does not require religious employers to cover infertility treatment.


• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility.

Exceptions

• The law does not require insurers to cover fertility drugs, IVF or other assisted reproductive techniques, reversal of a tubal ligation, a vasectomy, or any other method of sterilization.


• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• The patient and the patient’s spouse must have a history of infertility for 2 years or the infertility is associated with one of the following: endometriosis; DES exposure; blocked or surgically removed fallopian tubes; abnormal male factors contributing to the infertility.


• The patient’s eggs must be fertilized with her spouse’s sperm.


• The patient is the policyholder or a covered dependent of the policyholder.


• The patient has been unable to obtain successful pregnancy through any less costly infertility treatments covered by insurance.

Coverage

• Individual and group insurance policies that provide pregnancy-related benefits must cover the cost of 3 IVFs per live birth.

Lifetime maximum of $100,000.

• IVF procedures must be performed at clinics that conform to ASRM and ACOG Guidelines.

Exceptions

• Does not require religious employers to cover infertility treatment.


• Employers with fewer than 50 employees do not have to provide coverage.


• Employers who self-insure are exempt from the requirements of the law.

MASSACHUSETTS 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/Patient Requirements

• Infertility means the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1-year or 6-month period.


• Coverage


• All insurers providing pregnancy-related benefits shall provide for the diagnosis and treatment of infertility including the following: artificial insemination; IVF; GIFT; sperm, egg and/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; ICSI; ZIFT; assisted hatching; cryopreservation of eggs.


• Conceiving but having a miscarriage does not restart the 1-year or 6-month clock to qualify as having infertility.


• Insurers shall not impose any exclusions, limitations or other restrictions on coverage of infertility drugs that are different from those imposed on any other prescription drugs, nor shall they impose deductibles, copayments, coinsurance, benefit maximums, waiting periods or any other limitations on coverage for required infertility benefits which are different from those imposed upon benefits for services not related to infertility.


• The law does not limit the number of treatment cycles and does not have a dollar lifetime cap. Insurers may set limits based on their clinical guidelines and patients' medical histories.

Exceptions

• Insurers are not required to cover (but are not prohibited from covering) experimental infertility procedures, surrogacy, or reversal of voluntary sterilization.


• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• Infertility is not defined in the law or regulation.

Coverage

• Requires HMOs to cover infertility services as part of basic health care services.

Exceptions

• Employers who self-insure are exempt from the requirements of the law.

NEW JERSEY 2001
NJ Laws, Chap. 236

Definition of Infertility/Patient Requirements

• Infertility means a disease or condition that results in the abnormal function of the reproductive system such that: a male is unable to impregnate a female; a female under 35 years of age is unable to conceive after two years of unprotected sexual intercourse; a female 35 years of age and over is unable to conceive after one year of unprotected sexual intercourse; the male or female is medically sterile; or o the female is unable to carry a pregnancy to live birth.


• Infertility does not mean a person who has been voluntarily sterilized regardless of whether the person has attempted to reverse the sterilization.


• Must be less than 46 years of age.


• The patient has been unable to obtain successful pregnancy through any less costly infertility treatments covered by insurance.

COVERAGE

• Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to:


• artificial insemination;


• assisted hatching;


• diagnosis and diagnostic testing;


• fresh and frozen embryo transfers;


• 4 completed egg retrievals per lifetime;


• IVF, including IVF using donor eggs and IVF where the embryo is transferred to a gestational carrier or surrogate;


• ICSI;


• GIFT;


• ZIFT;


• medications;


• ovulation induction; and


• surgery, including microsurgical sperm aspiration.


• The procedures must be performed at facilities that conform with ACOG and ASRM guidelines.

Exceptions

• Employers with fewer than 50 employees do not have to provide coverage.


• Cryoperservation is not covered.


• Nonmedical costs of egg or sperm donor are not covered.


• Infertility treatments that are experimental or investigational are not covered.


• Does not require religious employers to cover infertility treatment.


• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility.


• The law abides by the ASRM definition of infertility. ASRM defines infertility as the inability to achieve a pregnancy after trying for 12 months if you are under 35 and 6 months if you are over 35.


• Coverage is provided to patients 21 to 44 years old.


• Patients must be covered under their insurance policy for at least 12 months before receiving infertility coverage.

Coverage

• Group policies must provide diagnostic tests and procedures that include:


• hysterosalpingogram;


• hysteroscopy;


• endometrial biopsy;


• laparoscopy;


• sono-hysterogram;


• post coital tests;


• testis biopsy;


• semen analysis;


• blood tests and


• ultrasound


• Every policy that provides for prescription drug coverage, shall also include drugs (approved by the FDA) for use in the diagnosis and treatment of infertility.

Exceptions

• Excludes coverage for IVF, GIFT, and ZIFT; reversal of elective sterilizations; sex change procedures; cloning or experimental medical or surgical procedures.


• Employers who self-insure are exempt from the requirements of the law.

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

Coverage

• Requires HMOs to cover “basic health care services” including infertility services, when they are medically necessary.


• Diagnostic and exploratory procedures are covered, including surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs including, but not limited to: endometriosis; collapsed/clogged fallopian tubes; testicular failure.


• IVF, GIFT and ZIFT may be covered, but are not required by the law.

Exceptions

• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertility/Patient Requirements

• Infertility means the condition of an otherwise presumably healthy married individual who is unable to conceive or produce conception during a period of two years.

Coverage

• Insurers and HMOs that cover pregnancy benefits, must provide coverage for medically necessary expenses of diagnosis and treatment of infertility.


• Coverage is provided to women between the ages of 25 and 40.


• The law imposes a $100,000 cap on treatment.


• The insurer may impose up to a 20% co-payment.

Exceptions

• Employers who self-insure are exempt from the requirements of the law.

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

Definition of Infertilty/Patient Requirements

• Requires group insurers to offer coverage of IVF. Employers may choose whether or not to include infertility coverage as part of their employee health benefit package.


• If an employer chooses to offer the benefit, patients must meet the following: the patient for the IVF procedure is the policyholder or spouse of the policyholder; the patient’s eggs must be fertilized with her spouse’s sperm; the patient and the patient’s spouse have a history of infertility of at least five continuous years or associated with endometriosis, DES, blockage of or surgical removal of one or both fallopian tubes or oligospermia; the patient has been unable to attain a pregnancy through less costly treatment covered under their policy; the IVF procedures must be performed at medical facilities that conform to 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 1995 W.Va. Code Section 33-25A-2

Definition of Infertility/Patient 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.