Model Bill: Fertility Care Coverage Act

Section 1: Short Title

This bill shall be known as “Fertility Care Coverage Act”

Section 2: Definitions.

As used in the following section, unless the context otherwise indicates, the following terms have the following meanings.

1. ‘‘Infertility”– as defined by The American Society for Reproductive Medicine (ASRM)– is as a disease, condition, or status characterized by any of the following:
   1. The inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.
   2. The need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner.
   3. In patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.

1. “Fertility diagnostic care” means procedures, products, medications and services intended to provide information and counseling about an individual’s fertility, including laboratory and assessments and imaging studies.

1. “Fertility patient” means (a) an individual or a couple experiencing infertility, (b) an individual or a couple who is at increased risk of transmitting a serious inheritable genetic or chromosomal abnormality to a child, (c) an individual unable to achieve a pregnancy as an individual or with a partner because the individual or couple does not have the necessary gametes to achieve a pregnancy, or (d) an individual or couple for who uses fertility preservation services.

1. “Iatrogenic infertility” means an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

1. “Fertility treatment” means procedures, products, medications, and services intended to achieve pregnancy and a live birth with healthy outcomes, and that are provided in a manner consistent with established medical practice and professional guidelines published by the American Society for Reproductive Medicine.

1. “Standard fertility-preservation services” means (A) procedures, products,  medications and services intended to preserve fertility, consistent with established medical practice and professional guidelines published by the American Society for Reproductive Medicine, and (B) includes, but is not limited to, the procurement and cryopreservation of gametes, embryos and reproductive material, and storage from the date of cryopreservation.

1. “In vitro fertilization” (IVF) is where eggs are taken from a person’s ovaries and fertilized with sperm in a laboratory. The resulting fertilized egg (embryo) may be placed into the uterus to establish a pregnancy.

1. “Intrauterine insemination” (IUI) is a procedure that places sperm into a woman’s uterus around the time of ovulation.

1. “Gamete” means a cell containing a haploid complement of deoxyribonucleic acid that has the potential to form an embryo when combined with another gamete. “Gamete” includes sperm and eggs.

1.  “Experimental fertility procedure” means a procedure for which  the published medical evidence is not sufficient for the American Society for Reproductive Medicine.

Section 4: Required Coverage

An insurance carrier offering a health plan in [STATE] shall provide coverage: A) For fertility diagnostic care; B) For fertility treatment if the enrollee is a fertility patient; and C) For fertility preservation services.

1. Insurers and HMOs that cover pregnancy benefits must also cover medically necessary expenses associated with diagnosis and treatment of infertility, and standard fertility preservation services when a medically necessary medical treatment may directly or indirectly cause iatrogenic infertility to a covered person.

1. The coverage mandate applies to any health insurance contract, plan, or policy delivered, issued, or renewed in [STATE], including Medicaid and other governmental programs, that provides pregnancy-related benefits.

1. The benefits shall be provided to the same extent as for other pregnancy-related procedures and medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles, and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract.

1. Insurers must provide fertility treatment including, but not limited to:
   1. diagnosis and diagnostic tests;
   2. treatment and surgery for medical conditions related to infertility, including, but not limited to, fibroids, polyps, endometriosis, polycystic ovary syndrome (PCOS), and varicocele;
   3. medications;
   4. intrauterine insemination (IUI);
   5. in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate;
   6. gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT);
   7. genetic testing;
   8. genetic testing of embryos;
   9. medical costs of donor gametes, donor eggs, donor sperm, and surrogacy services.
   10. 4 completed egg retrievals and unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician;
   11. standard fertility preservation services.
       1. Each health carrier that issues or renews any group policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide coverage for fertility preservation when a person is expected to undergo surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment of fertility.
       2. This includes coverage for standard fertility preservation services, including the procurement and cryopreservation of embryos, eggs, sperm, and reproductive material determined not to be an experimental infertility procedure. Storage shall be covered from the time of cryopreservation for the duration of the policy term. Storage offered for a longer period of time, as approved by the health carrier, shall be an optional benefit.

Section 5: Limitations on coverage.

1. A health plan that provides coverage for the services required by this section may include reasonable limitations to the extent that these limitations are not inconsistent with the following requirements and rules adopted by the bureau.
   1. A carrier may not impose a waiting period.
   2. A carrier may not use any prior diagnosis or prior fertility treatment as a basis for excluding, limiting, or otherwise restricting the availability of coverage required by this section.
   3. A carrier may not impose any limitations on coverage for any fertility services based on an enrollee’s use of donor gametes, donor embryos, or surrogacy.
   4. A carrier may not impose different limitations on coverage for, provide different benefits to, or impose different requirements on a specific class of persons.
   5. A carrier may not impose deductibles, copayments, coinsurance, benefit maximums, or any other limitations on coverage for the diagnosis and treatment of infertility, including the prescription of fertility medications, different from those imposed upon benefits for services not related to infertility.
   6. Any limitations imposed by a carrier must be based on an enrollee’s medical history and clinical guidelines adopted by the carrier.
   7. Any clinical guidelines used by a carrier must be based on current guidelines developed by the American Society for Reproductive Medicine, must cite with specificity any data or scientific reference relied upon, must be maintained in written form, and must be made available to an enrollee in writing upon request.

(B) Any health insurance policy issued pursuant to subsection shall not be required to provide coverage for:

1. Any experimental fertility procedure. “Experimental fertility procedure” means a procedure for which  the published medical evidence is not sufficient for the American Society for Reproductive Medicine.

Section 6: Insurance Requirements

1. [DEPARTMENT OF HEALTH OR RELEVANT STATE AGENCY] shall adopt necessary rules not different or more burdensome and consistent with the content of this act. Health insurance carriers shall fulfill their obligations under this act by conforming to the standards of ASRM.
2. [DEPARTMENT OF HEALTH OR RELEVANT STATE AGENCY] shall amend the Medicaid state plan to provide fertility treatment coverage in accordance with this act.

Section 7: Effective Date

This law shall become effective on MONTH DAY, YEAR and  shall apply to all policies, contracts, and health benefit plans issued, delivered, amended, or renewed in the [STATE] on or after [DATE].