Health Reform does not appear to make

Infertility Coverage

any more available than before Resolve  as infertility is  not a mandated Essential Benefit, although Maternity (page 9 & 85)  and newborn care is.

Some insurers are now required 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; (class action lawsuit?) nor does it force employers to include it in their employee insurance plans. (California Health and Safety Code §1374.55)

Infertility is defined 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. (§1374.55)

Treatment includes, but not limited to:

  • Diagnosis and diagnostic tests;
  • Medication;
  • Surgery; and
  • Gamete Intra fallopian Transfer, also known as GIFT.§1374.55

Insurers do not have  to offer in 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, §1374.55 American Society of Reproductive Medicine Website)

Infertility in a specimen Individual Obamacare EOC Policy

Exclusions

Infertility Page 111

Rx to treat infertility

Definition of Infertility page 165

 

Consumer Links

embrace a child.org/

International Council on Infertility Information Dissemination
(INCIID – pronounced “inside”) is a nonprofit organization helping patients explore their family-building options

National Infertility Assoc – Insurance Section

Pre – Existing Conditions?

Underwriting Guidelines on California Department of Insurance Website.

Fertility Insurance Program  —  covers the serious financial risks of medical complications, disability and death potentially incurred by those who decide to pay for and undergo such infertility medical treatment themselves and for their donor(s) or surrogate(s).  FIP Frequently Asked Questions   bbtexas.com

Infertility Treatment:  Exclusions – Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to, diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal, and gamete intrafallopian transfer. $1,500 EOC (Evidence of Coverage)
Survey of State Laws on Infertility Coverage

AB 1083 & 1672 Guaranteed Issue for Employer Groups

Costs of Infertility Treatment

Medical Policy Bulletins – Various Companies – Search Tools

Fertility Preservation Treatment

Aetna Clinical Bulletin

IRS would allow a tax deduction  for infertility treatment

Insurance Coverage for Infertility

CIGNA’s Position Paper on Infertility

Child Pages


 

Technical Links

Yeager v Blue Cross 2009

http://www.medicoverage.com/health-insurance-blog/news/is-in-vitro-covered-by-obamacare

 

winfertility.com/the-affordable-care-act-and-how-it-effects-infertility-patients/

 

Infertility Coverage vs. Availability

The ACA does not mandate infertility treatment coverage. According to Sean Tipton, Director of Public Affairs for the American Society for Reproductive Medicine (ASRM), “The ACA is completely silent on infertility.” And while states can require their insurance companies to cover infertility treatments, according to ASRM only 15 (Massachusetts, Maryland, Connecticut, Rhode Island, Arkansas, California, Hawaii, Illinois, Louisiana, Montana, New Jersey, New York, Ohio, Texas and West Virginia) require at least some infertility insurance coverage. Barbara Collura, President and CEO of RESOLVE: The National Infertility Association, has stated that such states can either add infertility coverage as an essential health benefit in plans sold on their Exchanges, or they can drop their mandate.

 

fertilityauthority.com/costs/california-infertility-insurance-mandate

 

healthinsurance.org/does-the-aca-require-infertility-treatment-to-be-covered-by-health-insurance/

Knight v Hayward

Pending Class Action Lawsuit vs. Blue Cross

More details Status on Court Website Case # BC353402

Plaintiffs have a motion set for March, in which they are trying to establish that the small benefit Blue Cross offers does not comply with the requirements of California law. Both Health & Safety Code sec. 1374.55 and Ins. Code sec. 10119.6 require insurers to offer coverage for “treatment for infertility.” The statutes define that as coverage for all medically recognized diagnostic and treatment services, except they are not required to offer coverage for the actual laboratory procedures involved in IVF. The actual lab procedures are just the fertilization of the egg in a special dish or tube (maybe one-tenth the typical cost of an IVF “cycle”)–thus, health insurers are required to offer coverage for everything else related to IVF although, as best the attorney for the plaintiff knows, and our own research above, none of them do

Text of Law 1374.55
. Coverage for treatment of infertility;
applicable plans; exceptions

 

(a) On and after January 1, 1990, every health care service plan contract which is issued, amended, or renewed that covers hospital, medical, or surgical expenses on a group basis, where the plan is not a health maintenance organization as defined in Section 1373.10, shall offer coverage for the treatment of infertility, except in vitro fertilization, under those terms and conditions as may be agreed upon between the group subscriber and the plan. Every plan shall communicate the availability of that coverage to all group contract holders and to all prospective group contract holders with whom they are negotiating.

(b) For purposes of this section, “infertility” means either

  • (1) the presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or
  • (2) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.

“Treatment for infertility means procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intra fallopian transfer. “In vitro fertilization” means the laboratory medical procedures involving the actual in vitro fertilization process.

(c) On and after January 1, 1990, every health care service plan which is a health maintenance organization, [HMO] as defined in Section 1373.10, and which issues, renews, or amends a health care service plan contract that provides group coverage for hospital, medical, or surgical expenses shall offer the coverage specified in subdivision (a), according to the terms and conditions that may be agreed upon between the group subscriber and the plan to group contract holders with at least 20 employees to whom the plan is offered. The plan shall communicate the availability of the coverage to those group contract holders and prospective group contract holders with whom the plan is negotiating.

(d) Nothing in this section shall be construed to deny or restrict in any way any existing right or benefit to coverage and treatment of infertility under an existing law, plan or policy.

(e) Nothing in this section shall be construed to require any employer that is a religious organization to offer coverage for forms of treatment of infertility in a manner inconsistent with the religious organization’s religious and ethical principles.

(f) Nothing in this section shall be construed to require any plan, which is a subsidiary of an entity whose owner or corporate member is a religious organization, to offer coverage for treatment of infertility in a manner inconsistent with that religious organization’s religious and ethical principles.

For purposes of this subdivision, “subsidiary” of a specified corporation means a corporation more than 45 percent of the voting power of which is owned directly, or indirectly through one or more subsidiaries, by the specified corporation.

(A.B.2474), § 1, eff. Sept. 14. 1990.)

“The Legislature finds and declares the following:

“(1) Infertility is a significant health problem that affects millions of Californians.

“(2) Infertility is a medical illness or condition similar to other illnesses or conditions that is created by the malfunction of other bodily organs, and thus is no different than other illnesses of conditions and should be treated for purposes of insurance the same as any other body dysfunction.

“(3) If properly treated, successful pregnancies can result in 70 percent of the cases.

“(4) Insurance coverage for infertility is uneven, inconsistent, and frequently subject to arbitrary decisions which are not based on legitimate medical considerations.”
West’s Ann. Cal. Health & Safety Code § 1374.55, CA HLTH & S § 1374.55

2 comments on “Infertility

  1. I have learned that infertility is difficult to get covered.

    I was referred to an infertility clinic by an emergency room nurse after my wife suffered a miscarriage. The infertility clinic told me they have a relationship with a medical group called Healthcare Partners.

    My insurance company at the time, Blue Cross, did not allow me to use that medical group so I shopped around and found out that LA Care HMO would allow me to use them; they were on their list. I double checked with LA CARE Covered (through the Affordable Health Care Act)

    [ http://www.quotit.net/eproIFP/webPages/infoEntry/InfoEntryZip.asp?license_no=0596610 ] and they told me that, in reference to infertility, as long as my wife was referred to an in house clinic by Healthcare Partners, we were covered.

    In other words, the fertility clinic and Healthcare Partners were associated and therefore LA Care would cover most of the expenses involved as long as my wife was referred by her primary physician for infertility and HealthCare Partners approved that referral. I called twice about this and both times I was told the same thing.

    [We told Matt we didn’t think infertility would be covered as it’s not an essential benefit http://healthreformquotes.com/individual/metal-levels/10-essential-benefits/ plus the exclusions in the specimen policy.

    Thus showing how important the right to have an agent at no additional cost is http://healthreformquotes.com/welcome/home/role-of-agent

    So, incredibly, we were allowed to switch to LA CARE covered (which was unusual since open season was over but Obomacare was new and exceptions were being made), [ http://healthreformquotes.com/individual/missed-open-enrollment/special-enrollment-triggering-events/ ] and my wife’s primary physician for Healthcare Partners cooperated and referred my wife to a fertility specialist (who would then refer her to the associated clinic) and Health Care Partners approved her referral. So it was all working out.

    And then just before we were set to go to the appointment to the Fertility GYN specialist, I received a call from the GYN office that LA Care would not cover the expense. Apparently the two women I talked with from LA CARE Covered got it wrong, even though they were answering the phone and responding to exactly these types of questions all the time. I’m sure it wasn’t intentional but I learned that you must be diligent and read everything yourself and not rely on what is told to you.

    On a positive note, through my wife’s primary physician, practically all of the blood work for the clinic was covered because the physician was aware of what the clinic needed and specifically ordered those tests for my wife’s physical and it was approved an non-fertility testing.

    I brought those tests to the fertility clinic and it saved me some money.

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