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Not every health insurance plan is subject to state regulation. If your employer buys a plan through a health insurance company, then state regulations apply. Some states mandate that health insurance companies cover infertility treatment. But if your employer has a self-funded benefits program, your health coverage is regulated by the federal ERISA law, which has no provision for infertility treatment. Certain other plans, such as those purchased by you individually or by religious institutions and school districts, are also likely exempt from state regulation.
If you have a group health plan through work, the best way to determine whether or not your plan is subject to state regulation is to ask your benefits manager.
For more, read about paying the price for infertility.
Where infertility coverage is mandated
Group health plans subject to regulation in these states must provide infertility coverage as part of the plan.
Arkansas: Mandates all individual and group health insurance carriers (excluding HMOs) cover in vitro fertilization (IVF), and allows insurers to impose a lifetime benefit cap of $15,000.
California: Infertility treatment is covered excluding IVF, but including gamete intra-fallopian transfer (GIFT). Group health insurers covering hospital, medical or surgical expenses must let employers know infertility coverage is available.
Connecticut: Mandates individual and group insurance carriers to provide coverage of comprehensive infertility diagnosis and treatment, including assisted reproductive-technology procedures, and IVF to group policyholders. Infertility coverage must be offered to patients under age 40.
Hawaii: Mandates all individual and group health insurance carriers to cover one cycle of in vitro fertilization if certain conditions have been met.
Illinois: Mandates that group insurance carriers and HMOs cover diagnosis and treatment of infertility if they also offer pregnancy-related coverage. Insurance carriers are not required to provide this benefit to businesses (group policies) of 25 or fewer employees.
Louisiana: 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.
Maryland: Mandates that individual and group insurance policies that provide pregnancy-related benefits must cover the cost of three IVFs per live birth. There is a lifetime maximum of $100,000. Insurance carriers are not required to provide this benefit to businesses (group policies) of 50 or fewer employees.
Massachusetts: 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. There is no limit of treatment cycles and no lifetime dollar cap.
Montana: Mandates HMOs to cover infertility treatment as part of basic health care service.
New Jersey: Mandates that group insurers and HMOs that provide pregnancy-related coverage must provide infertility treatment, but do not have to cover experimental treatments. Insurance carriers are not required to provide this benefit to businesses with 50 or fewer employees.
New York: Mandates group health insurers to cover diagnostic tests and procedures and prescription drug coverage for use in the diagnosis and treatment of infertility. However, this mandate excludes coverage of in vitro fertilization and other procedures.
Ohio: Mandates HMOs to cover infertility treatment as basic health care services when medically necessary. Diagnostic and surgical procedures are mandated, but in vitro fertilization and other procedures are not mandated.
Rhode Island: Mandates insurance carriers and HMOs that cover pregnancy-related benefits to also provide coverage for medically necessary expenses of diagnosis and treatment of infertility. The coverage mandate applies only to women between the ages of 25 and 40. There is a $100,000 cap on treatment and the insurer may impose up to a 20 percent co-payment.
West Virginia: Mandates HMOs to cover infertility treatment as part of basic health care services.
Where infertility coverage must be offered
Group health plans subject to regulation in these states must offer this coverage with their plans, but purchasers (such as employers) can decide not to buy it.
Texas: Mandates group insurance carriers that provide pregnancy-related benefits to offer coverage of infertility diagnosis and treatment, in addition to in vitro fertilization.
Source: Resolve: The National Infertility Association.
