The Connecticut state infertility insurance law mandates that “certain individual and group health policies to cover medically necessary costs of diagnosing and treating infertility”. Coverage for IVF is mandated with limits.
Like any regulation the devil is in the details. Not every CT resident who is trying to conceive is assured of having every infertility treatment procedure covered by insurance.
There are several important points to know:
- What are the key requirements and definitions?
- What are the limits and exclusions?
- How does ObamaCare affect the law?
CT State Infertility Insurance Requirements
The Connecticut state infertility insurance mandate has fairly broad requirements. Other state infertility mandates are far more narrowly focused. Either the laws require fewer health plans to comply, or specific infertility treatments are excluded.
The Connecticut act is “applicable to individual and group health policies that cover basic hospital expenses; basic medical surgical expenses; major medical expenses; hospital or medical service plans contracts; and, hospital and medical coverage provided to subscribers of a health care center that are delivered, issued, amended, renewed or continued on or after October 1, 2005″. The key term in 2014 is “individual” as we will see later on when addressing the impact of the Affordable Care Act (ObamaCare).
The Connecticut state infertility insurance mandate defines infertility as “the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one year period”.
The law provides that covered medically necessary expenses of the diagnosis and treatment of infertility include, but are not limited to:
- Ovulation induction up to 4 cycles
- Intrauterine insemination up to 3 cycles
- Uterine embryo lavage
- Embryo transfer
- Gamete intra-fallopian transfer (GIFT)
- Zygote intra-fallopian transfer (ZIFT)
- Low tubal ovum transfer
CT Insurance IVF
The CT infertility insurance law mandates coverage for In Vitro Fertilization (IVF). The plan must provide life-time benefits of two IVF cycles, limited to two embryo transfers per cycle.
The IVF benefit is limited to individuals who have been unable to conceive through other less expensive infertility treatments covered under the plan. Benefits are subject to preapproval by the carrier, leaving a large gray area of interpretation. When has the individual tried enough other alternative treatments before IVF benefits may be approved?
The law also requires disclosure from the covered individual of any infertility treatments that may have been covered under another plan. Changing plans to reset the lifetime limit does not appear to be a lawful maneuver.
Remember that your objective is to get pregnant. Connecticut maternity leave laws do not provide for paid family leave. Short-term disability in CT may replace a portion of income during a pregnancy leave, and while recovering from childbirth. The policies must start prior to conception, so the timing is perfect.
The CT infertility mandate contains limitations that carriers are allowed to impose on plan benefits.
Carriers may institute a separate tier for prescription fertility drugs. Many plans have a tiered plan with varying copay and coinsurance amounts: generics, preferred, and name brand tiers are most common. The allowable range for copays is up to $40, and coinsurance can go as high as 50%. Given the cost of many fertility drugs you might expect to see coinsurance used more heavily as this cost the insurer less – but you far more.
Managed care organizations (HMO and/or PPO) may confine benefits to in network providers only. This means you must find a fertility clinic that accepts your specific health plan. Otherwise your entire cost must be paid out of pocket.
Limits on Fertility Treatments
Specific infertility treatment costs are not included in the mandate such as: sperm and egg donor costs, expenses related to any resulting pregnancies and deliveries that may result, reversal of sterilizations such as tubal ligation and/or vasectomies, gestational carriers, and surrogate arrangements.
There is one other potentially large hole: the act mandates that plans carriers determine medical necessity.
The CT State infertility insurance law has exclusions that may apply to certain residents. The exclusions fall into three categories: membership qualifications, religious organizations, and out of state headquartered employers.
You must have been a member of your plan for at least twelve months before infertility treatments are covered. That means shopping around for a new plan requires that you wait before starting your next procedure. Also, any infertility procedures performed in the past must be disclosed to your new carrier.
Any religious organization is entitled to opt out of coverage if the methods of diagnosing and treating infertility are contrary to their moral values. The carrier would then issue a rider to the policy excluding infertility coverage.
Out of State Employer Headquarters
The law can only be enforced when Connecticut has jurisdiction to regulate. If your employer is headquartered in another state, your health plan may not be subject to this mandate. If you commute into New York or Massachusetts then your insurance plan may be regulated by those state laws. Check the laws for the state where your employer is headquartered.
The law regulates health insurance companies, not employers. If you work for a large employer that self insures, you may not be covered. Check with your HR department before undergoing infertility treatments. The Connecticut law also applies only to women up to age 40.
ObamaCare and the CT Infertility Law
The Affordable Care Act (ObamaCare) may impact the number of individuals subject to the CT state infertility insurance mandate, and raise costs for unreimbursed expenses.
As noted above the CT law applies to individual as well as group plans. The plans required to comply are qualified by language describing a basic set of benefits the plan must cover in order to be subject to the requirements. The Affordable Care Act institutes a set of ten essential health benefits that all individual plans must meet. These essential health benefits assure that every individual plan will meet these criteria.
Unreimbursed Medical Expenses
The Affordable Care Act may increase the after tax costs of unreimbursed medical expenses. While the essential health benefits raise the bar for what needs to be included in a plan, the need to make the coverage affordable means the larger deductibles, and co-insurance may result. Infertility may be covered, but at a lower percentage than in the past.
The Affordable Care Act contained two provisions making these unreimbursed expenses cost more. The threshold for deductible medical expenses was raised from 7.5% of Adjusted Gross Income (AGI) to 10.0%. Also limits were placed on the amounts that could be contributed to a Flexible Spending Account – $2,500 annually. Both provisions raise the after-tax cost of infertility treatments.