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Old 07-28-2003, 01:24 PM   #1
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Join Date: May 2003
Location: Los Angeles, CA, USA
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owenville HB User
Post Infertility Coverage by State

I always see a lot of posts about what states are "must cover" states and what states are "must offer" states.

Thought I'd post the following info for newbies or those who want to know . This list only shows states that have some type of law on the books. If your state isn't on the list, there might be a pending law, or no law at all that requires coverage.

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. However, 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

This law requires health insurers to offer coverage for infertility diagnosis and treatment -- including in vitro fertilization. That means 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 employee insurance plans.

The law defines infertility as the condition of a presumably healthy individual who, over the course of a year is:

Unable to get pregnant; or
Unable to keep or carry a pregnancy to term. (Connecticut General Statutes Annotated, Section 38a-536).
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

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. That means 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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Old 07-28-2003, 01:34 PM   #2
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Join Date: Dec 2002
Posts: 537
ams37 HB User
Talking

thanks Owenville!
We had to switch my hubs insurance co. too. His insurance is out of state..and we had to get insurance in MASS> ! It covers IUIS and IVF thankfully.,
We are paying about 600.00 a month for ins. right now..My husband had good coverage (BC/BS) EVERYTHING BUT INFERTILITY OF COURSE! they need to mandate every single state to have coverage......................... they cover everything else..........
A girl can have an abortion and its covered yet HAVING a baby ISN'T covered.......... I don't get it!!!!!!!!!!!!
Anne

 
Old 07-28-2003, 01:43 PM   #3
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Join Date: May 2003
Location: Los Angeles, CA, USA
Posts: 107
owenville HB User
Post

I'm covered in Mass. too. We're based in CA, but my DH's co. is headquartered in Mass, so we have the luck of being covered there. He just tried to switch jobs and the co. had NO fertility coverage at all, not even diagnostics. Ugh.

I'm glad abortion is covered by many companies, but you're totally right that it's RIDICULOUS that having children isn't.

 
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