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April
9

New York law mandating IVF coverage starts January 1, 2020

The New York Assembly passed a law compelling large group plans (more than 100) to offer In Vitro Fertilization (IVF). The law provides that large group plans offer 3 rounds of IVF. Additionally for all plans, the law mandates fertility preservation services, such as egg or sperm freezing, for members whose medical treatment will render them infertile, such as cancer patients who need radiation.

The law does not apply to public and self funded plans.

Who’s eligible for IVF? Anyone who receives insurance through the large-group market (employees at businesses with 100 or more employees) and who is diagnosed with infertility, which the law defines as an incapacity to conceive following 12 months of regular, unprotected sex or donor insemination. Women age 35 and older are considered infertile after only six months.

What IVF services are covered? The law requires coverage for three cycles of IVF over a member’s lifetime, including any medications prescribed in connection with the service, even if the health plan does not otherwise include a prescription drug benefit. Egg and/or embryo storage is also covered if it’s considered medically necessary while the three IVF cycles are underway.

What counts toward the three cycles? A frozen embryo transfer cycle counts toward the three-cycle limit. A cycle that was begun but not finished also counts. A cycle paid for by the member out of pocket, or covered by another health insurance plan, does not count. Cycles completed prior to 2020 also do not count.

What about fertility preservation services? Who’s eligible? Individuals whose medical treatment will directly or indirectly impair their fertility (such as cancer patients undergoing radiation or individuals seeking gender-affirming surgery) are eligible so long as they are also part of an individual, small- or large-group insurance plan that provides hospital, surgical, medical, major medical or comprehensive care.

What services are covered? Standard fertility preservation services — including the collecting, preserving and storage of eggs or sperm — must be covered, including any prescription drugs used in the process.

For how long? It’s unclear how long insurers must cover the storage of eggs or sperm. The law does not include a specific time limit for storage, and gives health plans the option to review this service for medical necessity

Will either service — IVF or fertility preservation — cost me anything? Probably. Health plans can impose deductibles, copayments and coinsurance on the services, but those charges must be consistent with other covered services.

What about red tape? Insurers may require prior authorization for these services, meaning the provider must check with the insurer first to make sure the service is covered before providing it. Insurers can also review the services to determine if they are medically necessary. You should also check your plan’s network coverage rules. If your plan only provides for in-network benefits, service coverage could be limited to in-network providers — unless the insurer doesn’t have an in-network provider with appropriate training and expertise. If the plan covers out-of-network services, coverage for out-of-network IVF or fertility preservation services must also be provided.

What can’t my insurer do? Unlike IVF services, insurers cannot impose a lifetime limitation on fertility preservation services. For both IVF and fertility preservation services, your insurer cannot impose an annual dollar limit or age restriction. They also cannot discriminate based on a member’s expected life span, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, or personal characteristics such as age, sex, sexual orientation, marital status or gender identity.

More information on the law can be found at the New York State Financial Services site.