Massachusetts Infertility & IVF Coverage
Massachusetts infertility and IVF health insurance is mandated by state law.
The Massachusetts infertility law mandates that general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits, also provide coverage for diagnosis and treatment of infertility, including in vitro fertilization (IVF).
That statement raises several questions which are addressed below in more detail:
- Who is covered?
- What treatments are included?
- Where are the holes?
- How can you fill them?
Massachusetts Infertility Insurance - Who Is Covered
The Massachusetts infertility insurance mandate applies more broadly and with fewer holes than in other states. The mandate applies to "all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth".
Somehow MA has determined that it can impose its rules on medical plans issued in other states. If you work in MA but your employer is headquartered elswhere you may be lucky. You may also need to contact the state department of insurance if your employers insurer is unaware of this requirement and your participation in the plan - many times employers overlook unusual requirements, and this fits the bill.
Another key consideration is whether your health plan provides pregnancy benefits. Confirm coverage with your employer before beginning infertility treatments. Massachusetts also require that medical plans cover prenatal care and pregnancy related conditions on policies sold to individuals and small groups. In most cases your plan will need to comply.
Some Massachusetts insurers deny infertility coverage if the female partner smokes, not providing coverage unless the woman undergoes a smoking cessation program, followed by a urine test to detect nicotine in the body.
Massachusetts Definition of Infertility
The Massachusetts mandate updated the definition of inferitlity in 2010.
"Infertility' shall mean the condition of an individual
who is unable to conceive or produce conception during a period of 1 year if
the female is age 35 or younger or during a period of 6 months if the female is
over the age of 35.
For purposes of meeting the criteria for infertility in
this section, if a person conceives but is unable to carry that pregnancy to
live birth, the period of time she attempted to conceive prior to achieving
that pregnancy shall be included in the calculation of the 1 year or 6 month
period, as applicable.”
What is Procedures are Covered?
The Massachusetts mandate stipulates that all insurers shall provide benefits for non-experimental infertility procedures including:
Prescription fertility drugs are to be covered to the same extent as drugs for other medical conditions.
What Treatments are Excluded?
The MA law specifically excludes health care plans from having to cover:
- Experimental infertility treatments
- Reversal of voluntary sterilizations
- Cryopreservation of eggs
How to Fill the Holes?
No matter how good your medical plan, it will have some holes. Depending upon your plan design some holes will be bigger than others. You may experience un-reimbursed medical expenses in the following areas:
- Co pays - for testing, monitoring, and drug therapies may accumulate quickly
- Co insurance - is common when using out of network clinics
- Amounts above allowed charges - may be charged in addition to co insurance when using out of network providers
- Policy limits - the mandate requires that benefits be paid for "medically necessary treatment”. Your insurer gets to decide what is necessary.
Any expenses not covered by your medical plan may be tax deductible. Learn how the rules work for making these deductions on Schedule A, and/or by using your flexible spending account at work. Both have advantages and disadvantages and may work differently for every couple.
Remember that Massachusetts has very rich benefit requirements for infertility, prenatal and pregnancy care, and even a rule providing job protection for women taking maternity leave. But there is no requirement for maternity leave pay. Purchase short term disability for pregnancy before beginning your next ART procedure.