State Laws Related to Insurance Coverage for Infertility Treatment

6/12/2019

Approximately 10 percent of U.S. women of childbearing age have received assistance for infertility. Usually, infertility is defined as the absence of conception after at least one year of regular, unprotected intercourse. Common methods of infertility treatment include various insemination techniques and hormone therapy to stimulate egg production. Assisted reproductive technology (ART) are procedures in which pregnancy is attempted through the use of external means; for example, eggs are fertilized outside the womb and then placed into a woman's uterus through in vitro fertilization (IVF). More than 72,913 babies were born in the United States in 2015 as a result of non-donor ART procedures. The Centers for Disease Control and Prevention estimate that ART accounts for slightly less than two percent of total U.S. births.

Although advances in infertility treatment have helped thousands of couples become parents, the procedures are not without controversy. Such procedures can be quite expensive— according to the University of Iowa Stead Family Children's Hospital each cycle of IVF costs $12,000 to $17,000 on average and there is debate about whether insurance plans should cover them. Studies have shown that pregnancy resulting from ARTs are associated with a higher risk of pregnancy complications compared to spontaneously conceived pregnancies.

Since the 1980s, 16 statesArkansas, California, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia—have passed laws that require insurers to either cover or offer coverage for infertility diagnosis and treatment. Of those states, fourteen have laws that require insurance companies to cover infertility treatment and two states—California and Texas—have laws that require insurance companies to offer coverage for infertility treatment.

Some of these laws are unique— for example Utah requires insurers providing coverage for maternity benefits to also provide an indemnity benefit for adoption or infertility treatments. Louisiana and New York prohibit the exclusion of coverage for a medical condition otherwise covered solely because the condition results in infertility. Minnesota specifies that medical assistance will not provide coverage for fertility drugs when specifically used to enhance fertility. While most states with laws requiring insurance companies to offer or provide coverage for infertility treatment include coverage for in vitro fertilization, CaliforniaLouisiana, and New York have laws that specifically exclude coverage for the procedure.

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State Laws Related to Infertility Treatments

State

Summary of Statutes

Arkansas

Ark. Stat. Ann. § 23-79-510 specifies that the Arkansas Comprehensive Health Insurance Pool shall not include coverage for any expense or charge for in vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy.

Ark. Stat. Ann. § 23-85-137 and § 23-86-118 (1987, 2011) require accident and health insurance companies to cover in vitro fertilization. Services and procedures must be performed at a facility licensed or certified by the Department of Health and conform to the guidelines and minimum standards of the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine. (2011 SB 213)

California

 

Cal. Health & Safety Code § 1374.55 and Cal. Insurance Code § 10119.6 require specified group health care service plan contracts and health insurance policies to offer coverage for the treatment of infertility, except in vitro fertilization. The law requires every plan to communicate the availability of coverage to group contractholders. The law defines infertility, treatment for infertility and in vitro fertilization. The law clarifies that religious employers are not required to offer coverage for forms of treatment that are inconsistent with the organization's religious and ethical principles. The law was amended by 2013 Cal. Stats., Chap. 644 (AB 460) to specify that treatment of infertility shall be offered and, if purchased, provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation.

Connecticut

Conn. Gen. Stat. § 38a-509 and § 38a-536 (1989, 2005) require that health insurance organizations provide coverage for medically necessary expenses in the diagnosis and treatment of infertility, including in vitro fertilization procedures. Infertility, in this case, refers to an otherwise healthy individual who is unable to conceive or produce conception or to sustain a successful pregnancy during a one-year period. Amended in 2005 to provide an exemption for coverage that is contrary to the religious beliefs of an employer or individual.

Delaware 18 Del. C. §3556 (2018) requires all group and blanket health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in the state of Delaware by any health insurer, health service corporation, or health maintenance organization and that provide for medical or hospital expenses shall include coverage for fertility care services, including in vitro fertilization services for individuals who suffer from a disease or condition that results in the inability to procreate or to carry a pregnancy to live birth and standard fertility preservation services for individuals who must undergo medically necessary treatment that may cause iatrogenic infertility.

Hawaii

Hawaii Rev. Stat. § 431:10A-116.5 and § 432.1-604 (1989, 2003) require all accident and health insurance policies that provide pregnancy-related benefits to also include a one-time only benefit for outpatient expenses arising from in vitro fertilization procedures. In order to qualify for in vitro fertilization procedures, the couple must have a history of infertility for at least five years or prove that the infertility is a result of a specified medical condition.

Illinois

Ill. Rev. Stat. ch. 215, § 5/356m (1991, 1996) requires certain insurance policies that provide pregnancy-related benefits to provide coverage for the diagnosis and treatment of infertility. Coverage includes in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete sperm artificial intrafallopian tube transfer, zygote intrafallopian tube transfer and low tubal ovum transfer. Coverage is limited to four completed oocyte retrievals, except if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals are covered. (1996 Ill. Laws, P.A. 89-669)

Louisiana

La. Rev. Stat. Ann. § 22:1036 prohibits the exclusion of coverage for the diagnosis and treatment of a medical condition otherwise covered by the policy, contract, or plan, solely because the condition results in infertility.  The law does not require insurers to cover fertility drugs, in vitro fertilization or other assisted reproductive techniques, reversal of a tubal litigation, a vasectomy, or any other method of sterilization. (2001 La. Acts, P.A. 1045)

Maryland

Md. Insurance Code Ann. § 15-810 (2000) amends the original 1985 law and prohibits certain health insurers that provide pregnancy-related benefits from excluding benefits for all outpatient expenses arising from in vitro fertilization procedures performed. The law clarifies the conditions under which services must be provided, including a history of infertility of at least a 2-year period and infertility associated with one of several listed medical conditions. An insurer may limit coverage to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000. The law clarifies that an insurer or employer may exclude the coverage if it conflicts with the religious beliefs and practices of a religious organization, on request of the religious organization.  Regulations that became effective in 1994 exempt businesses with 50 or fewer employees from having to provide the IVF coverage. (2000 Md. Laws, Chap. 283; H.B. 350)

Md. Health General Code Ann. § 19-701 (2000) includes family planning or infertility services in the definition of health care services. 

Massachusetts

Mass. Gen. Laws Ann. ch. 175, § 47H, ch. 176A, § 8K, ch. 176B, § 4J, ch. 176G, § 4 and 211 Code of Massachusetts Regulations 37.00 (1987, 2010) require general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits to also provide coverage for the diagnosis and treatment of infertility, including in vitro fertilization. This law was amended in 2010 to change the definition of  "infertility" to be a condition of an individual who is unable to conceive or produce conception during a period of one year if the female is under the age of 35, or during a period of six months if the female is over the age of 35. If a person conceives but cannot 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 one year or six month period. (SB 2585)

Minnesota

Minn. Stat. Ann. § 256B.0625 specifies that medical assistance shall not provide coverage for fertility drugs when specifically used to enhance fertility.

Montana

Mont. Code Ann. § 33-22-1521 (1987) revises certain requirements of Montana's Comprehensive Health Association, the state's high-risk pool, and clarifies that covered expenses do not include charges for artificial insemination or treatment for infertility. (SB 310)

Mont. Code Ann. § 33-31-102 et seq. (1987) requires health maintenance organizations to provide basic health services on a prepaid basis, which include infertility services. Other insurers are exempt from having to provide the coverage.

New Jersey

N.J. Stat. Ann. § 17:48-6x§ 17:48A-7w§ 17:48E-35.22 and § 17B:27-46.1x (2001) require health insurers to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility, including medications, surgery, in vitro fertilization, embryo transfer, artificial insemination, gamete intrafallopian transfer, zygote intrafallopian transfer, intracytoplasmic sperm injection and four completed egg retrievals per lifetime of the covered person. The law includes some restrictions as well as a religious exemption for employers that provide health coverage to fewer than 50 employees. (SB 1076)

New York

N.Y. Insurance Law § 3216 (13), § 3221 (6) and § 4303(1990, 2002, 2011) prohibit individual and group health insurance policies from excluding coverage for hospital care, surgical care and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility. The laws were amended in 2002 to require certain insurers to cover infertility treatment for women between the ages of 21 and 44 years. The laws exclude coverage for in vitro fertilization, gamete intrafallopian tube transfers and zygote intrafallopian tube transfers. The laws were amended again in 2011 by N.Y. laws, Chap. 598 to require every policy that provides coverage for prescription fertility drugs and requires or permits prescription drugs to be purchased through a network participating mail order or other non-retail pharmacy to provide the same coverage for prescription fertility drugs that are purchased from a network participating non-mail order retail pharmacy provided that the network participating non-mail order retail pharmacy agrees in advance to the same reimbursement amount and the same terms and conditions that the insurer has established for a network participating mail order or other non-retail pharmacy.  The policy is prohibited from imposing additional fees, co-payments, co-insurance, deductibles or other conditions on any insured person who elects to purchase prescription fertility drugs through a non-mail order retail pharmacy. (2011 AB 8900)


N.Y. Public Health Law § 2807-v (2002) creates a grant program to improve access to infertility services, treatments and procedures from the tobacco control and insurance initiatives pool.

Ohio

Ohio Rev. Code Ann. § 1751.01 (A)(1)(h) (1991) requires health maintenance organizations (HMOs) to provide basic health care services, which are defined to include infertility services, when medically necessary.

Rhode Island

R.I. Gen. Laws § 27-18-30, § 27-19-23, § 27-20-20 and § 27-41-33 (1989, 2007)require any contract, plan or policy of health insurance (individual and group), nonprofit hospital service, nonprofit medical service and health maintenance organization to provide coverage for medically necessary expenses for the diagnosis and treatment of infertility. The law clarifies that the co-payments for infertility services not exceed 20 percent. Infertility is defined as the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year.  Rhode Island includes IVF coverage.  Amended in 2007 to increase the age of coverage for infertility from forty (40) to forty-two (42) and redefines infertility to mean a woman who is unable to sustain pregnancy during a period of one year. (2007 R.I. Pub. Laws, Chap. 411, SB 453)

Texas

Tex. Insurance Code Ann. § 1366.001 et seq. (1987, 2003) requires that all health insurers offer and make available coverage for services and benefits for expenses incurred or prepaid for outpatient expenses that may arise from in vitro fertilization procedures. In order to qualify for in vitro fertilization services, the couple must have a history of infertility for at least five years or have specified medical conditions resulting in infertility.  The law includes exemptions for religious employers.

Utah

2014 Utah Laws, Chap. 353 (HB 347) amended § 31A-22-610.1, which requires insurers that provide coverage for maternity benefits to also provide an adoption indemnity benefit of $4,000 for a child placed for adoption with the insured within 90 days of the child’s birth. The law was amended to allow an enrollee to obtain infertility treatments rather than seek reimbursement for an adoption. If the policy offers optional maternity benefits, then it must also offer coverage for these indemnity benefits under certain circumstances.

West Virginia

W. Va. Code § 33-25A-2 (1995) amends the 1997 law and requires health insurers to cover basic health care services, which include infertility services.  Applies to health maintenance organizations (HMOs) only.

Sources: The National Conference of State Legislatures and the American Society for Reproductive Medicine: State Infertility Insurance Laws.
Note: List may not be comprehensive, but is representative of state laws that exist. NCSL appreciates additions and corrections.      

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