Essential Health Benefit Plans and Infertility State Mandates

by Davina Fankhauser
President - Fertility Within Reach

Fertility Within Reach has reviewed the Essential Health Benefit (EHB) plans for states with some form of mandated infertility benefit.  The objective was to identify which states would have infertility treatment as a minimum benefit among it’s state insurance plans and which states are at risk of losing their mandated infertility benefits.

  • The Affordable Care Act asked states to identify which insurance plan they would like to represent their minimum coverage and still meet the requirements of the Dept. of Health and Human Services, Essential Health Benefits.
  • The EHB plan is the minimum standard for other insurance policies within the state.  Therefore, any state with infertility treatment within their EHB plan would also see infertility treatment within other insurance policies.
  • States that did not include infertility benefits in the EHB plan, but have a mandated infertility benefit, face having to pay the cost associated with the mandated coverage.   These states are at particular risk of losing their mandated infertility benefit.
  • States had the option to recommend an insurance plan to be the EHB or use the default plan.  Any state that did not participate in this process were assigned the Default plan.
    • The recommended plan may or may not provide infertility benefits
    • The default plan does not include infertility benefits

Findings:

Infertility Mandated State EHB Benchmark Plan Status Plan Name IVF Benefits
Arkansas Recommended HMO Partners Open Access POS NO
California Recommended Kaiser- Small Group, HMO NO
Connecticut Recommended ConnectiCare, HMO CT plan is not final
Hawaii Recommended Hawaii Medical Service Association (BCBS)- Preferred   Provider Plan 2010, PPO NO
Illinois Recommended BCBS of IL- BlueAdvantage Entrepreneur, PPO YES
Louisiana Default BCBS of LA- GroupCare, PPO NO
Maryland Recommended CareFirst (BCBS)- HMO HSA Open Access MD (Individual Plans Only)
Massachusetts Recommended BCBS of MA- HMO Blue YES
Montana Default BCBS of MT- Blue Dimensions, PPO NO
New Jersey Default Horizon (BCBS)- HMO Access NO
New York Recommended Oxford, EPO NO
Ohio Default Community Insurance Company (Anthem BCBS)- Blue   Access, PPO NO
Rhode Island Recommended BCBS of RI- Vantage Blue PPO YES
Texas Default BCBS of TX- BestChoice, PPO NO
West Virginia Default Highmark (BCBS of WV)- Super Blue Plus 2000, PPO NO
Summary:
15 States
9 Recommended
6 Default
3 group
1 individual
1 TBD

More information can be found at http://www.ncsl.org/issues-research/health/state-ins-mandates-and-aca-essential-benefits.aspx#Appendix 3

Special notes to point out:

  • The American Society for Reproductive Medicine was active in Maryland to ensure infertility patients within the state had the option to purchase a plan which would provide infertility benefits.  Great job ASRM!!!
  • Fertility Within Reach worked in Massachusetts to ensure the state selected an EHB plan which would require infertility benefits amongst all insurance plans within the state.

 

Call to Action:

  • States with an infertility mandate, but lack EHB infertility coverage may create legislation to eliminate the current mandated infertility benefit.  It is critical to contact your legislator and ask them to protect the infertility mandated benefit in your state.

 

  • Connecticut still has yet to determine the specific design of its plan.  There is still time to communicate why having infertility as part of the EHB is important.
    • Written comments may be submitted by any interested party at any time to the Exchange, directed to the attention of: Julie Lyons, Director of Policy and Plan Management, Connecticut Health Insurance Exchange, 450 Capitol Avenue, Hartford, CT 06106.

 

When it comes to understanding how the Affordable Care Act will impact infertility health benefits in your state, we are a resource for you.  Please don’t hesitate to contact us with any questions you may have.

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Davina Fankhauser

President - Fertility Within Reach

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