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. (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;
- Surgery; and
- Gamete Intra fallopian Transfer, also known as GIFT.§1374.55
Insurers do not have to offer in vitro fertilization coverage.
2019 (Fertility Preservation)
California Health & Safety Code Section 1374.551
Text of Law1374.55
Definition of Infertility/Patient Requirements
- Requires group insurers to offer coverage of infertility treatment, except IVF In Vitro Fertilization. Employers may choose whether or not to include infertility coverage as part of their employee health benefit package.
(b) For purposes of this section, “infertility” means either
- (1) the presence of a demonstrated condition … 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 … the treatment of infertility … 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.
- “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.
- 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.
- Only requires insurers to offer infertility treatment coverage.
- Does not include IVF.
- Does not require religious organizations to offer coverage. (California Health and Safety Code, Section 1374.55, §1374.55 American Society of Reproductive Medicine Website) Scroll down for more information
- 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 *
“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.”
Be sure to read the ENTIRE LAW 1374.55 and not just our summary!
Insurance Coverage for Infertility
|Additional Blue Shield Infertility Benefits for Your HSA Plan|
|Additional Blue Shield Infertility Benefits for Your PPO Plan|
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/
Infertility Coverage vs. Availability
The ACA does not mandate infertility treatment coverage. California requires at least some infertility insurance coverage. .
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)
Website Video #Introduction
- 17 Reasons to use Steve Shorr Insurance
- Set a Meeting
Our Webpage on Insurance Coverage for
Chabad Redondo Beach – Rabbi Zalman Gordon – Podcast on
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.
We will update this in 2021 as there are improvements in coverage!
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.
International Council on Infertility Information Dissemination
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
Birth Control & Abortion Mandates
Rules Under Health Care Reform
Trump moves to force CA to not mandate abortion on health plans LA Times 1.24.2020 *
Pro Choice – By Joel Harrison
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.
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