Infertility Coverage

ACA/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 and newborn care is.

Cancer patients now mandated to get fertility options! LA Times 10.13.2019 *

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)

See NEW LAW  – Fertility Preservation Act 2019 §1374.551!

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)

Text of Law §1374.55
. Coverage for treatment of infertility

 

(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

 
 

2019 (Fertility Preservation)  Cal. Health & Safety Code  Section 1374.551  

 

Definition of Infertility/Patient Requirements

 

  • Requires group insurers to offer coverage of infertility treatment, except IVF In Vitro FertilizationEmployers 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.
  • “Iatrogenic infertility” means infertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment.
  • “Standard fertility preservation services” means procedures consistent with the established medical practices [medical necessity?] and professional guidelines published by the American Society of Clinical Oncology or the American Society for Reproductive Medicine.

Coverage

  • No infertility treatment coverage is required. Insurers are only required to offer the following services to employers who decide if they will provide the following benefits to their employees: diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT).
  • When a covered treatment may cause iatrogenic infertility to an enrollee, standard fertility preservation services are a basic health care service; these provisions are declaratory of existing law that requires every health care service plan contract to provide enrollees with basic health care services.

Exceptions

  • Only requires insurers to offer infertility treatment coverage.
  • Does not include IVF.
  • Does not require religious organizations to offer coverage.
  • Fertility preservation coverage does not apply to Medi-Cal managed care health care service plan contracts.
  • Employers who self-insure are exempt from the requirements of the law.  Resolve *

ACA/Obamacare 

Diagnosis and treatment of underlying medical cause of Infertility is covered for all plans through the medical benefit — this is an EHB (Essential Health Benefit) requirement.
 
 
Medical Necessity   Medical Policies & Clinical UM (utilization management) Guidelines very technical

Insurance Coverage for Infertility

 

 

Additional Blue Shield Infertility Benefits for Your HSA Plan
Additional Blue Shield Infertility Benefits for Your PPO Plan

Blue Cross CA Small Group Flyer with rates (Rev 9.2018)

Conception by artificial means

Except for artificial insemination covered under “Infertility Services” in the “Benefits and Cost Sharing” section, all other Services related to conception by artificial means, such as ovum transplants, gamete intrafallopian transfer (GIFT), semen and eggs (and Services related to their procurement and storage), in vitro fertilization (IVF), and zygote intrafallopian transfer (ZIFT) are not covered.

Coverage for newborn thru surrogate pregnancy. New Life Agency.com/

EOC Evidence of Coverage

Infertility Services Exclusion Removed

We removed the infertility services exclusion. Your plan covers services associated with an infertility related diagnosis.  Blue Shield Update *

Check your EOC – Evidence of Coverage – for what you have.

Infertility in a specimen Individual Obamacare EOC Policy  2014

2020 Blue Shield Silver 70 Direct – Not Covered CA – Trio HMO 

We will update this in 2021 as there are improvements in coverage!

Exclusions

Infertility Page 111

Rx to treat infertility

Definition of Infertility page 165

Abortion must be medically necessary

Exclusion for voluntary

We also like EOC’s as they are mandated to be written in Plain English, so you don’t have to read all the laws and court cases.  

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

Alternatives – Solutions

You might try doing a  Bronze Plan with a high deductible and lower premiums, click here for FREE Quotes in CA – Nationwide,  then using an  HSA Plan  (Health Savings Account) or for Small Employers Section 105 HRA and writing off the infertility expenses that are not covered?

Learn More ⇒  (IRS Publication 502 Medical & Dental Expenses)

Blue Cross 40% discount – Winfertility

Consumer Links

embrace a child.org/

International Council on Infertility Information Dissemination

CIGNA’s Position Paper on Infertility
More from a search on CIGNA’s website

National Infertility Assoc – Insurance Section

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

Costs of Infertility Treatment

Fertility Preservation Treatment

Aetna Clinical Bulletin

IRS would allow a tax deduction  for infertility treatment

Birth Control & Abortion Mandates

Rules Under Health Care Reform

10 Essential Benefits + CA Benefits

 

Abortion

Trump moves to force CA to not mandate abortion on health plans  LA Times 1.24.2020 *

California Attorney General suing Trump over the confusion

10.2.2014  Catholic Group files complaint over CA Abortion Coverage Rules  CA Health Line

Pro Choice – By Joel Harrison

Birth Control

Article on Birth Control by Joel Harrison, whom I was a camp counselor with at San Diego JCC.

Supreme Court to decide if Birth Control can be required, mandate blocked 12.31.2013 New York Times. * Modern Health Care 1.1.2014

U.S. Supreme Court ruled that closely held companies can claim a religious exemption from the Affordable Care Act’s requirement that they offer birth control coverage in their employer health plans CA Health Line *

Hobby Lobby Case

The “Hobby Lobby case” challenged the ACA requirement to provide coverage for certain family planning and contraceptive services (Plan B, IUDs, etc.). Certain employers claimed that this requirement was offensive to their religious beliefs and violated their rights under the Religious Freedom Restoration Act of 1993 (“RFRA”).

The Supreme Court held that the plaintiffs in this case, and other similarly situated closely held corporations with similar religious beliefs, cannot be required to provide contraceptive coverage under the ACA. It’s important to note that this holding applies only to contraceptives and not to other insurance requirements (e.g. transfusions, immunizations, etc.). In addition, the Court noted that the federal government currently has in place a less restrictive alternative to ensure coverage/payment for contraceptives for the employees of such employers – specifically, the federal accommodation for religious-affiliated non-profit entities, which Blue Shield of California implemented late last year. The Court pointed to this federal accommodation as something the federal government may extend to the type of employers at issue in this case (closely held, for-profit corporations).

This decision relies on the provisions of the RFRA, which applies only to the laws and regulations of the federal government and agencies. It does not apply to the laws of states, including California. Because underwritten plans must comply with state law and California’s existing state law requiring coverage for contraceptive drugs and devices is not invalidated by the holding in this case, it is anticipated that the primary impact will be to Administrative Services Only (ASO) plans and not to underwritten plans.

Next steps

Blue Shield’s Legal department will be analyzing this decision in more detail and will be providing further analysis and recommendations in the near future.  Blue Shield Agent Bulletin 2014 

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Infertility is hard to talk about. How the internet makes it harder — and easier  LA Times 4.29.2019

 

Chabad Redondo Beach – Rabbi Zalman Gordon – Podcast on 

Many of our early ancestors including Abraham and Sara, Isaac and Rebecca and Jacob and Rachel suffered with infertility. Today, we have modern medical solutions including in vitro fertilization that allows for couples that would otherwise be infertile to have children.
What is the Jewish perspective on infertility? Why does G-d give some people children and not others? Should those who are infertile, spare all expense and effort to have children? Does Jewish law allow infertility treatments?
The Jewish perspective on infertility and infertility treatments.

 

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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