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Health Ins. Issues State by State

Arkansas law requires all health insurers that provide maternity benefits to cover the cost of in vitro fertilization (IVF)  Patients need to meet the following conditions to qualify: The patient must be the policyholder or the spouse of the policyholder and also be a covered individual as defined by the policy; The patient's eggs must be fertilized with her spouse's sperm.  The patient and her spouse must have at least a two-year history of unexplained infertility, unless the infertility is associated with: Endometriosis; exposure to iethylstilbestrol, also known as DES; Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization; or Abnormal male factors contributing to the infertility.
 
The IVF benefits are subject to the same deductibles and co-insurance payments as maternity benefits. The law also permits insurers to limit coverage to a lifetime maximum of $15,000.   HMO's are exempt from having to provide IVF benefits.  (Arkansas Statutes Annotated, Sections 23-85-137 and 23-86-118).


California law requires group health insurers providing hospital, medical or surgical expenses to offer infertility coverage. The law does not require those insurers to provide the coverage; nor does it force employers to include it in their employee insurance plans.
 
Unlike Arkansas, California requires only a one year history of infertility 
 
California 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).

 

Connecticut health insurance policies are required to cover medically necessary expenses for infertility diagnosis and treatment. Coverage is limited to individuals who have maintained coverage under the policy for at least a year, and are under 40 years of age;  There is a life-time coverage maximum of four cycles of ovulation induction, three cycles of IUI, and two cycles of IVF, GIFT, ZIFT, or low tubal embryo transfer (with not more than two embryo transfers per cycle);

 

Like California, the infertility history has to be at least one year and religious employers are permitted to exclude coverage for treatments that are conflicts with their religious and ethical purposes. (Public Act No.05-196)


Hawaii requires insurance plans to provide a one-time only benefit for outpatient treatment for in vitro fertilization (IVF) when the policy provides pregnancy-related benefits. 

 

Patients need to meet the following conditions in order to get their IVF covered: Like Arkansas, the patient's eggs must be fertilized with her spouse's sperm, however, the patient or the her spouse must have at least a five-year history of infertility, and the infertility must be associated with Endometriosis,Fetal exposure to diethylstilbestrol, also known as DES, blocked or surgically removed fallopian tubes; or Abnormal male factors contributing to the infertility. (Hawaii Revised Statutes, Sections 431-lOA-116.5 and 432.1-604).

 

 

Illinois requires insurance policies that cover more than 25 people and provide pregnancy-related benefits must also provide coverage for the diagnosis and treatment of infertility. Like California, infertility has to have been documented for one year.
 
The law exempts religious organizations which believe the covered procedures violate their religeous beliefs. (Illinois Compiled Statutes Annotated, Chapter 215, Sections 5/356m and 125/5-3).


Maryland requires insurance policies that provide pregnancy-related benefits to also cover the outpatient costs of in-vitro fertilization.  Coverage is mandatory for persons who live and work in the state, regardless of whether the policy is issued inside or outside the state.  Unlike California, HMO's must provide IVF benefits to the same extent as the benefits provided for other infertility services.
 
Like California;  the patient's eggs must be fertilized with her spouse's sperm, however the history of infertility must be greater than two years or  the infertility is due to Endometriosis, Fetal exposure to diethylstilbestrol, also known as DES, Blocked or surgically removed fallopian tubes; or Abnormal male factors.
 
Coverage may be limited to three in vitro fertilization attempts per live birth and a maximum lifetime benefit of $100,000.
 
Exemptions include religious organizations when their religious beliefs conflict with the treatment as well as businesses with 50 or fewer employees. (Maryland Insurance Article §15-810, Health General Article §19-706).

 

Massachusetts requires health maintenance organizations and insurance companies that provide pregnancy-related benefits to also cover the medically necessary expenses of infertility diagnosis and treatment when the period of infertility is greater than one-year.  (Annotated Laws of Massachusetts, Chapters 175,§ 47H; 176A,§8K;176B,§4J; and l76G,§4, 211 CMR 37.00).


Montana  requires health maintenance organizations to cover infertility services as part of basic preventive health care services but specifically excludes all other insurers from providing coverage. (Montana Code Annotated, Sections 33-22-1521 and 33-31-102).


New Jersey requires group insurance for employers having more than 50 people and which provide pregnancy-related benefits to also cover the cost of the diagnosis and treatment of infertility. Like other states, New Jersey requires a history of greater than two years of infertility but allows coverage to be denied when the patient is over 45 years of age.
 

The state allows religious organizations to request an exclusion when it is contrary to the religious employer's religious beliefs. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48E-35.22 Health Service Corporations; 26:2J-4.23 Health Maintenance Organizations)


New York requires coverage for the diagnosis and treatment of correctable medical conditions including infertility when the infertile patient is between the ages of 21 and 44, and who has been a covered individual for at least 1 year.  (New York Consolidated Laws, Insurance, Section 3221(k)(6), Section 4303(s).)


Ohio requires health maintenance organizations cover basic preventive health services, including infertility, but only when the infertility treatment is medically necessary.  (Ohio Revised Code Annotated §1751)
  
Rhode Island requires insurers and HMO's that provide pregnancy services to also cover the cost of medically necessary expenses of diagnosis and treatment of infertility. Like other states, Rhode Island requires the infertility to have existed at least one year.  (Rhode Island General Laws (§ 27-18-30, 27-19-23, 27-20-20 and 27-41-33).


Texas requires insurers that provide for pregnancy services to also offer coverage for in vitro fertilization.  While insurers must let employers know this coverage is available, employers do not have to include it in their plan.  To qualify for coverage patients must be the policyholder or the spouse of the policyholder and her eggs must be fertilized with her spouse's sperm.  Additionally, there must be a five-year history of unexplained infertility unless the infertility is associated with Endometriosis, Fetal exposure to diethylstilbestrol (DES), Blocked or surgical removal of one or both fallopian tubes, or Oligospermia.
 
Texas does not require religious groups to cover treatment that conflict with their religious and ethical beliefs. (Texas Insurance Code, Article 3.51-6).

West Virginia requires health maintenance organizations to cover basic health care services, including infertility services, when medically necessary.  (West Virginia Code §33-25A-2) 
 


 

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