Connecticut Infertility & IVF Insurance Law
Connecticut infertility and IVF health insurance is mandated by state law. The CT infertility health insurance law mandates that "certain individual and group health policies to cover medically necessary costs of diagnosing and treating infertility".
Before beginning any infertility treatment understand exactly how this law works:
There is one giant exception that is easily overlooked. The mandate does not require that your policy cover the resulting pregnancy. CT does not require individual or small group plans to cover normal pregnancy. The federal government requires this for groups of fourteen or more. Use supplemental maternity insurance to close the gap if you work for a small employer, bought an individual policy, or want to cover mom's income during maternity leave.
- Who is covered and who is not?
- What infertility treatments are mandated and how?
- Where are the holes and how to fill them?
Connecticut Law: Who is Covered?
The Connecticut infertility and IVF insurance mandate is quite broad.
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 Connecticut infertility health insurance law 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".
CT Mandate: Who is Not Covered?
Connecticut infertility and IVF insurance is not automatically available to every CT resident.
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.
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.
Exclusions and Limitations
There are a variety of exclusions and 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.
Specific ART protocols 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.
Covered Infertility Treatments