Insurance Mandate by State

Arkansas  | California | Connecticut | Hawaii  | Illinois | Louisiana | Maryland | Massachusetts
Montana | New Jersey | New York | Ohio | Rhode Island | Texas | West Virginia

State Year Source Coverage Patient Requirements Exemptions
Arkansas 1987 Arkansas Stat.Ann Sections 23-85-137,23-86-118
  • Individual and group insurance policies that cover maternity benefits must cover in vitro fertilization.
  • Lifetime maximum of $15,000.
  • Patients must have two (2) year history of infertility
  • Must use own egg and sperm
  • Must prove inability to conceive using less expensive treatments that are covered by insurance
  • HMOs
  • Self-Insured Employers
California 1989
  • California Health and Safety Code Section 1374.55
  • California Insurance Code Section 10119.6
  • Group insurers are required to offer Infertility treatment,except IVF.
    • Patients must experience inability to conceive or carry pregnancy to live birth after a year or more of regular sexual
      relations without contraception.
    • Limits pre-existing condition to 12 months.
    • Religious Organizations
    • Self-insured Employers
Connecticut 2005
  • Connecticut Gen.Stat.§38a-536 and §38a-509
  • Infertility diagnosis and treatment including IVF.
  • Lifetime maximums of:4 cycles of ovulation induction,3 cycles of intrauterine insemination,2 cycles of IVF, GIFT, ZIFT or low tubal ovum transfer
  • Maximum of 2 embryos transfered per cycle and each fertilization or transfer is counted toward the maximum.
  • Patients must experience inability to conceive or sustain a pregnancy to live birth during a one-year period
  • Religious Organizations
Hawaii
  • 1989
  • 2003
  • Hawaii Rev Stat.Sections 431:10A-116.5,432.1-604
  • Individual and group health insurance carriers must cover one cycle of in vitro fertilization.
  • Patient or spouse must have a 5 year history of infertility with at least one of the following conditions: endometriosis;DES exposure;blocked or surgically removed fallopian tubes;abnormal male factors contributing to the infertility
  • Patient’s egg must be fertilized with spouse’s sperm
  • Self-insured employers
Illinois
  • 1991
  • 1997
  • Ill. Rev. Stat ch 215,Section ILCS 5/356m
  • Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to: diagnosis of infertility;IVF;embryo transfer; artificial insemination;GIFT;ZIFT;low tubal ovum transfer.
  • Up to four (4) egg retrievals
  • If a live birth occurs, two (2) additional retrievals will be covered.
  • Maximum of six (6) retrievals covered
  • Unable to attain or sustain a successful pregnancy through reasonable, less costly, infertility treatments covered by insurance.
  • Self-Insured Employers
  • Religious Organizations
  • Businesses with fewer than 25 employees
Louisiana
  • 2001
  • LA State Law, Subsection 215.23, Acts 2001 No 1045 subsection
  • Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility
  • The law does not require insurers to cover fertility drugs, IVF or other assisted reproductive techniques,reversal of a tubal ligation, a vasectomy, or any other method of sterilization.
  • None mentioned
  • Self-Insured Employers
Maryland
  • 2000
  • MD Insurance Code Ann. Section 15-810
  • MD Health General Code Ann. Section 19-701
  • Individual and group insurance policies that provide pregnancy-related benefits must cover the cost of three (3) IVFs per live birth.
  • Lifetime maximum of $100,000
  • Patients must have history of infertility for two years or the infertility is associated with one of the following:endometriosis; DES exposure; blocked or surgically removed fallopian tubes; abnormal male factors contributing to the infertility.
  • Patient’s eggs must be fertilized with spouse’s sperm
  • Patient unable to obtain successful pregnancy through any less costly treatments covered by insurance.
  • Religious Organizations
  • Self-Insured Employers
  • Businesses with less than 50 employees
Massachusetts
  • 1987
  • 2010
  • Mass Gen Laws Ann. ch 175, Sec 47H, ch 176A, Sec 8K,ch 176B,Sec 4j,ch 176G, Sec 4, and 211 CMR 37.00
  • Mandates that insurance carriers that provide pregnancy-related benefits must cover comprehensive infertility
    diagnosis and treatment, including assisted reproductive-technology procedures, and not impose any exclusions, limitations or other restrictions on coverage of infertility drugs that are different from those imposed on any other prescription drugs
  • No limit of treatment cycles
  • No lifetime dollar cap
  • Massachusetts’ definition of “infertility” follows current American Society of Reproductive Medicine guidelines.
  • Individual unable to produce conception during a period of 1 year if the female is age 35 or younger and a period of 6 months if the female is over the age of 35
  • If a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable
  • Self-Insured Employers
  • Experimental Infertility Treatment
Montana
  • 1987
Mont.Code Ann.Section 33-22-1521,Section 33-31-102(2)(v)
  • HMOs are required to cover infertility treatment as part of basic health care service.
  • No further definition
    of infertility treatment is indicated.
  • Does not clarify if IVF is a covered treatment
none indicated
  • Self-Insured Employers
New Jersey
  • 2001
NJ Laws,Chap.236
  • Group insurers and HMOs must provide pregnancy-related coverage for the diagnosis and treatment of infertility, including medications
  • Maximum of 4 egg retrievals
  • Patient must be younger than 46 years old
  • Inability to obtain successful pregnancy through any less costly infertility treatments covered by insurance
  • Does NOT include:Cryopreservation,non-medical costs of donor egg/sperm,and experimental or investigational infertility treatments or patients that were voluntarily sterilized
  • Self-Insured Employers
  • Religious Organizations
  • Businesses with fewer than 50 employees
New York
  • 1990
  • 2002
NY Insurance Law Sections 3216 (13),3221
  • Group policies are prohibited from excluding coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility
  • Coverage includes diagnostic tests and procedures and prescription drugs for use in the diagnosis and treatment of infertility
  • Patient must be between the ages of 21-44 years old
  • Patient must have maintained their insurance policy for at least 12 months
  • Treatment must follow American Society for Reproductive Medicine Guidelines
  • Excluded procedures include:IVF,GIFT,ZIFT,reversal of voluntary sterilization,sex change,cloning,or experimental procedures
  • Self-Insured Employers
Ohio
  • 1991
Ohio Rev.
Code Ann. Section 1751.01(A)(7)
  • HMOs cover infertility treatment as basic health care services when medically necessary
  • Diagnostic and surgical procedures are mandated
  • IVF, GIFT, and ZIFT may be covered, but are not mandated
  • None noted
  • Self-Insured Employers
Rhode Island
  • 1989
  • 2006
RI Gen. Laws sections 27-18-30,27-19-23,27-20-20,and 27-41-33
  • Insurers and HMOs that cover pregnancy-related benefits must provide coverage for medically necessary expenses of diagnosis and treatment of infertility
  • Maximum $100,000
  • Insurer may impose up to a 20% co-payment
  • Presumably healthy married individual who is unable to conceive or produce conception during a period of one year
  • Women between the ages of 25 and 42
  • Self-Insured Employers
Texas
  • 1987
Tex. Insurance Code Ann. Section 3.51-6, Sec. 3A
  • Group insurance carriers that provide pregnancy-related benefits must offer employers benefit options including coverage for in-vitro fertilization
  • Patient’s eggs must be fertilized with spouse’s sperm
  • The patient and spouse must have a history of infertility for 5 continuous years or associated with endometriosis;DES;blockage or surgical removal of tubes
  • Patient must prove unable to obtain successful pregnancy through less costly treatment covered by insurance
  • Self-Insured Employers
  • Religious Organizations
West Virginia
  • 1995
W.Va. Code Section 33-25A-2
  • HMOs to cover infertility services as part of basic health care services
  • None Noted

Understanding State Mandates

Definitions:

  • State Mandate: any state initiated constitutional,statutory or executive action that requires a local government to establish, expand or modify its activities in such a way as to necessitate additional expenditures from local revenues, excluding any order issued by a state court and any legislation necessary to comply with a federal mandate.
  • Mandate to Offer:insurers must offer infertility benefits to the employers, but employers choose whether to add this benefit to their plan.
  • Mandate to Cover:requires insurers and employers to provide infertility treatment benefits. Some states offer coverage with specified exemptions (e.g.religious organizations, businesses with fewer than 25 employees, etc).
  • Self-Insured: company uses their own property or interests against possible loss by establishing a special fund for the purpose instead of seeking coverage with an underwriter (ref:dictionary.com).

Only 15 states have some form of mandated infertility treatment benefits. Self-insured companies are exempt from state mandates by the Employee Retirement Income Security Act. However,you will find companies,such as Gillette,who are self-insured and still provide infertility treatment benefits because they understand it’s “the right thing to do”.

Click here to see a list of such companies.

If your company does not provide coverage, we provide information and resources to help you approach your employers: Talking to Employers