26 Nov In Vitro Fertilization & Insurance Coverage
California has a fertility treatment insurance mandate in place which is based on the law (Section 1374.55 of the California Health and Safety Code) enacted in 1989. It is one of the 15 states that have an infertility insurance mandate in place to offer coverage or provide coverage for fertility treatment and IVF costs. According to this law, every health care service plan contract that covers hospital, medical, or surgical expenses, must offer coverage for fertility treatments.
Important caveats include that this law does not require insurers to provide the fertility treatment coverage, nor does it require employers to include it in the insurance plans for their employees. It also excludes in vitro fertilization (IVF) coverage from the requirement!
Coverage under California Fertility Treatment Insurance According to this law, infertility is defined as the presence of a condition diagnosed by a medical professional, such as a fertility doctor, as the cause of the infertility – the inability for the couple to conceive or carry a child to term after a year or more of unprotected sexual intercourse.
Fertility treatments covered under this mandate include infertility diagnostics, infertility tests, fertility medication, surgery, and gamete intrafallopian transfer (GIFT). However, in vitro fertilization is excluded from the requirement.
Employers from religious organizations are not required to offer coverage for fertility treatments that may be inconsistent with the religious organization’s religious and ethical principles.
It is for these reasons that many California couples have to pay out-of-pocket for a large portion of the overall costs of their infertility or IVF treatment. Financing IVF or any other infertility treatment can be cost-prohibitive for many households.
The Californian law requires health insurance plans to offer coverage for “medical procedures consistent with established practices in the treatment of infertility….”. But it is important to understand what procedures are covered, as you could easily end up having to pay 100% out-of-pocket.
The following categories have to do so as they are not covered:
- Employees of religious employers
- Employees of out-of-state companies
- People buying plans on the individual market
- Low-income earners enrolled in the Medi-Cal Medicaid program
- Employees at groups that decline the offer of infertility coverage
Generally speaking, employees are able to choose a plan from options provided by their employer, but the offered plans are limited to what the employer has chosen to offer. The insurance company often sets the “network” of physicians that an employee can see. Even if a patient has chosen a PPO plan, they are still limited to a certain network of physicians.
In case of fertility coverage actually being there, the patients’ next challenge is to discover the extent of it – whether they have only diagnostic (“dx”) benefits or treatment (“trx”) is also included. Moreover, having coverage does not mean there will be no cost. The benefits may “cap” at a certain amount, and anything more than the predetermined “cap” amount will have to be covered out-of-pocket by the patient.