Mandated Benefits Review - Senate Bill 1183 - Experience of Other States
Council staff examined related legislation from other states. Twelve states have addressed the issue of mandating infertility coverage in differing degrees.
Three of these twelve simply require insurers to offer infertility coverage but do not require employers to provide the coverage in their health plans. These states are California, Connecticut, and Texas.
Arkansas requires insurers to cover in vitro fertilization (IVF) only, not other treatments. HMOs are exempted from the mandate. Insurers may limit coverage to a lifetime maximum of $15,000.
Maryland requires coverage for in vitro fertilization only. HMOs and businesses having 50 or fewer employees are exempted.
Montana requires HMOs only to cover infertility services, specifically exempting other plan types.
Ohio requires HMOs only to cover infertility services. The plan may limit the coverage to $2,000 if the infertility is unexplained. If infertility results from a medical condition, the cap is removed.
New York requires insurers to cover the treatment of correctable medical conditions causing infertility (endometriosis, blocked fallopian tubes, etc.). Coverage of the treatment of unexplained infertility is not required. In vitro fertilization is not covered as a treatment of a correctable medical condition.
Hawaii provides for a one time benefit for in vitro fertilization only.
Illinois requires coverage for insurance policies covering 25 or more people. The coverage is comprehensive, not limiting the patient to a particular method, but it does limit the allowable number of egg retrievals to four.
Massachusetts requires very comprehensive coverage including costs associated with egg retrieval from a donor. In Massachusetts, it is estimated that the cost of such treatments adds approximately $2.25 to an average monthly policy amount of $562.50.
Rhode Island requires comprehensive coverage and limits the patient's copayment to 20%.
The definition of infertility varies among states. California, Connecticut, Illinois, Massachusetts, and Rhode Island all define infertility as an inability to conceive a pregnancy or carry to a live birth after one year of unprotected sex. Arkansas defines it as a two-year history of unexplained infertility or the presence of a medical condition. Hawaii requires both a five-year period of infertility and the presence of a medical condition. The other states did not exclude patients based on length of infertility.
Many states limit infertility coverage to married individuals. Arkansas, Hawaii, Maryland, and Texas all limit in vitro fertilization to eggs fertilized with the sperm of one's spouse.
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