The Massachusetts state infertility insurance law mandates coverage for infertility benefits including IVF. The law is perhaps the country’s most comprehensive, and passage of the Affordable Care Act may broaden both the number of people covered, as well as payable benefits.
Every regulation has key definitions, limits, and exceptions that are important to understand. Learn how the MA state infertility insurance mandate works.
- Key definitions
- Included and excluded treatments
- Affordable Care Act impact
- Individual plan design implications
MA Infertility Insurance Mandate Definitions
The Massachusetts infertility insurance mandate applies more broadly and with fewer holes than in other state infertility mandates. The legal language will not be repeated verbatim here. The law broken up into sections with very similar language based upon the type of insurance plan. Follow the citation links at the bottom of the page for precise definitions.
The goal of this page is to summarize key definitions in more understandable language. The key facts of greatest significance are those definitions for: infertility, covered members, and benefit amounts.
Definition of Infertility
The Massachusetts mandate updated the definition of infertility 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.”
Covered Members Definition
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 the state 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 elsewhere you may be lucky. You may also need to contact the state department of insurance if your employer’s insurer is unaware of this requirement and your participation in the plan – many times employers overlook unusual requirements, and this fits the bill.
Benefit Amounts Definition
The benefits amount definition is easily overlooked, but may be the most significant portion of the law. It reads as follows: “shall provide, to the same extent that benefits are provided for other pregnancy-related procedures, coverage for medically necessary expenses of diagnosis and treatment of infertility”.
The key phrase is “to the same extent”. This phrase takes on new meaning with the passage of the Affordable Care Act (ObamaCare). This law requires coverage for maternity and newborn care as an essential health benefit. It also abolished the practice of placing lifetime benefit limits. Combine the two together and you may yield unlimited benefits for infertility and IVF. See more below.
Mandated Infertility Treatments in MA
The MA state infertility insurance mandate stipulates that all insurers shall provide benefits for non-experimental infertility procedures. A specific list is provided.
There are several components of the Massachusetts mandate that warrant more attention when addressing In Vitro Fertilization (IVF). The requirement noted above requiring coverage to the “same extent” is most profound with IVF because of the costs involved. The mandate also includes language that prohibits placing arbitrary limits on benefits such as number of attempts, or dollar amounts. Check your policy language carefully.
MA law also requires any IVF clinic to provide educational materials regarding the disposition of unused pre-implantation embryos or gametes. The clinic must provide an informational pamphlet; the patient must sign an informed consent form, and the IVF procedure may not begin without an executed consent form.
The IVF mandate is particularly generous. But there is one item not covered: lost income and leftover medical expenses of a successful IVF procedure. Supplemental health insurance for infertility helps fill this gap.
Other Infertility Treatments
The following procedures are specifically included in the mandate.
- Artificial insemination
- Gamete Intra fallopian Transfer (GIFT)
- Intracytoplasmic Sperm Injections (ICSI)
- Zygote Intrafallopian Transfer (ZIFT)
- Cryopreservation of eggs
Prescription fertility drugs are to be covered to the same extent as drugs for other medical conditions.
The MA law specifically excludes health care plans from having to cover:
- Experimental infertility treatments
- Reversal of voluntary sterilizations
Couples considering a surgical reversal of an earlier sterilization may find assistance with zero percent infertility financing by using a flexible spending account.
Impact of ObamaCare on MA Mandate
The Affordable Care Act (ObamaCare) policies will become effective on January 1 of 2014. As addressed earlier the essential health benefits provision ensures that all individual plans cover maternity and newborn care, which may expand the number of plans needing to comply. The prohibition on lifetime benefit limits may also apply.
There is one unintended effect of the Affordable Care Act that people should pay close attention to: plan choices for individuals. While every plan must cover maternity and newborn care, as well as hospitalizations the plan level choice is now very important.
Individual Plan Choices
The Affordable Care Act (ACA) mandates four different plan designs: platinum, gold, silver, and bronze. Each level has a corresponding actuarial value: 90%, 80%, 70%, and 60% respectively. The average person picking the silver plan should expect the plan to cover 70% of actual medical expenses.
Anyone needing infertility treatment will probably incur medical expenses that will be far higher than average in two categories. First the cost of the infertility treatments themselves could be quite high – particularly if IVF is used. Second, the resulting pregnancies are often high risk and generate high levels of medical utilization.
Choose your plan accordingly. Higher premiums may make more sense.
The Affordable Care Act raised the costs of un-reimbursed medical expenses in two ways. Couples undergoing infertility treatments are likely to have left-over medical bills. These expenses are tax deductible, but the value of these deductions is diminished.
The ACA raised the deduction threshold from 7.5% of adjusted gross income to 10.0%, and lowered the contribution limit on flexible spending accounts to $2,500 per employee per year.
Massachusetts Funding Option
When a state level mandate mixes together with an Affordable Care Act provision the state level mandate continues only if the state agrees to fund the extra costs. It is uncertain at this time where Massachusetts stands on estimating any incremental costs associated with expanded access, and/or unlimited infertility benefits.