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Not every health plan is subject to state regulation. If your employer buys an insurance plan through a health insurance company,
then state regulations apply, such as any mandates that insurance cover
infertility treatment. But if your employer has a self-funded benefits
program, your health coverage is regulated only by the federal ERISA
law, which has no provision for infertility treatment. Certain other
types of plans, such as those purchased by you individually or by
religious employers and school districts, may also be exempt from state
regulation.
If you have a group health plan, the best way to
determine whether or not your plan is subject to state regulation is to
ask your benefits manager.
For more on this issue, read Paying the price for infertility.
Group health plans subject to regulation in these states must provide infertility coverage as part of the plan.
Arkansas:
Mandates all individual and group health insurance carriers (excluding
HMOs) cover in vitro fertilization, and allows insurers to impose a
lifetime benefit cap of $15,000.
California:
Mandates all insurance carriers to offer group policyholders coverage
of infertility diagnosis to patients under age 40. Infertility
treatment is covered excluding IVF, but including GIFT. Group health
insurers covering hospital, medical or surgical expenses must let
employers know infertility coverage is available.
Connecticut: Mandates individual
and group insurance carriers to provide coverage of comprehensive
infertility diagnosis and treatment, including assisted
reproductive-technology procedures, and IVF to group policyholders.
Hawaii:
Mandates all individual and group health insurance carriers to cover
one cycle of in vitro fertilization if certain conditions have been met.
Illinois:
Mandates that group insurance carriers and HMOs cover diagnosis and
treatment of infertility if they also offer pregnancy-related coverage.
Insurance carriers are not required to provide this benefit to
businesses (group policies) of 25 or fewer employees.
Maryland:
Mandates that individual and group insurance policies that provide
pregnancy-related benefits must cover the cost of three IVFs per live
birth. There is a lifetime maximum of $100,000. Insurance carriers are
not required to provide this benefit to businesses (group policies) of
50 or fewer employees.
Massachusetts:
Mandates insurance carriers to cover comprehensive infertility
diagnosis and treatment, including assisted reproductive-technology
procedures, and not impose any exclusions, limitations or other
restrictions on coverage of infertility drugs that are different from
those imposed on any other prescription drugs.
Montana: Mandates HMOs to cover infertility treatment as part of basic health care service.
New Jersey:
Mandates group insurers and HMOs that provide pregnancy-related
coverage must provide infertility treatment. Insurance carriers are not
required to provide this benefit to businesses with 50 or fewer
employees.
New York:
Mandates group health insurers to cover diagnostic tests and procedures
and prescription drug coverage for use in the diagnosis and treatment
of infertility. However, it excludes coverage of in vitro fertilization
and other procedures.
Ohio:
Mandates HMOs to cover infertility treatment as a basic health care
services when medically necessary. Diagnostic and surgical procedures
are mandated, but in vitro fertilization and other procedures are not
mandated.
Rhode Island: Mandates insurance
carriers and HMOs that cover pregnancy-related benefits to also provide
coverage for medically necessary expenses of diagnosis and treatment of
infertility. The coverage mandate applies only to women between the
ages of 25 and 40. There is a $100,000 cap on treatment and the insurer
may impose up to a 20 percent co-payment.
West Virginia: Mandates HMOs to cover infertility treatment as part of basic health care services.
Group
health plans subject to regulation in these states must offer this
coverage with their plans, but purchasers (such as employers) can
decide not to buy it.
Texas:
Mandates group insurance carriers that provide pregnancy-related
benefits to offer coverage of infertility diagnosis and treatment, in
addition to in vitro fertilization.
Source: Resolve: The National Infertility Association. Used with permission.
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