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New Jersey Infertility Mandate
New Jersey Infertility & IVF Health Insurance
New Jersey Infertility and IVF health insurance is mandated by state law.
The New Jersey Family Building Act is a state insurance law that requires health service corporations, hospital service corporations, health maintenance organizations, medical service corporations, and health insurance companies to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility.
Before starting any infertility treatment or IVF procedure know that the law does not apply to every NJ resident, and the mandate has limitations for which procedures are covered.
- Who is covered and who is not?
- What infertility treatments are covered and which are not?
- Where are the holes and how to fill them?
Supplemental Insurance for Pregnancy Insurance for infertility and IVF has one giant hole: what happens when mom experiences complications relating to a high-risk multiple pregnancy? NJ has state mandated disability coverage that may leave you with a big income gap. Purchase additional coverage before beginning your next infertility cycle to lock in your maternity benefit.
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Who is Covered by the NJ Infertility Mandate
The NJ Family Building Act applies to policies delivered, issued, executed or renewed in New Jersey for groups of 50 or more persons that provide hospital or medical benefits, including pregnancy-related benefits. That is a mouthful that needs to be pulled apart to better understand, plus there are other notable exceptions.
One key phrase is “in New Jersey”. Group policies that are issued in other states may not be bound by this statute. If you work in New Jersey for an employer that is headquartered in another state, your health plan may not be required to comply.
Groups of fifty or more employees are the only ones required to comply. If your employer has forty nine or fewer employees, your plan may not need to comply. Only plans that provide hospital or pregnancy related benefits are required to comply. Most group plans with more than fourteen employees are required to provide pregnancy related benefits, so most plans should have this feature. Pregnancy related benefits are defined as policies covering normal pregnancy and childbirth.
Certain government entitlement programs are exempt as well. Medical plans supporting NJ Family Care and Children’s Health Insurance Program are not required to comply.
Religious organizations are exempt from the requirement. This includes any church, convention, association of churches, or any entity that is operated or controlled by same.
Many larger employers self insure: meaning they fund benefit payments themselves using a combination of company resources and capital and employee contributions. As such they are not defined as an insurance company, medical services provider, etc. as defined in the law. This is a huge loophole in the law that couples need to understand. Check with your employer before committing any personal resources towards treatments.
New Jersey Definition of Infertility
The New Jersey law has a precise definition of infertility. Infertility is defined as a disease of the reproductive system that results in an abnormal function so that:
- The man is unable to impregnate a female
- The man and/or woman is sterile
- The woman is unable to carry her baby to live birth
- A female under the age of 35 is unable to conceive after two years of unprotected intercourse
- A woman over the age of 35 who is unable to conceive after one year of unprotected intercourse
What Infertility Procedures are Covered?
The NJ Family Building Act requires that infertility coverage is provided to the same extent as any pregnancy related procedure. The plan may not impose a separate copayment, deductible, or coinsurance, except limiting egg retrievals to four for the lifetime of each covered person. The carrier may not impose a separate of substantially different preauthorization requirement for any infertility treatment.
The carrier may limit benefits to services performed at facilities conforming to standards set by The American Society of Reproductive Medicine, or the American College of Obstetrics and Gynecologists. Specified infertility procedures that must be covered include:
- Artificial insemination - no limit on the number of cycles
- Assisted hatching - use of needle to assist the sperm in fertilizing the egg
- Diagnosis and diagnostic testing
- Fresh and frozen embryo transfer - four completed egg retrievals covered when live donor is used
- Gamete intrafallopian transfer (GIFT) - direct transfer of sperm and egg into the fallopian tube
- Zygote intrafallopian transfer (ZIFT) - egg is fertilized in vitro and transferred to the fallopian tube before cell division takes place
- Intracytoplasmic sperm injection (ICSI)
- In vitro fertilization - eggs are removed from a woman ’s body, fertilized in a dish, with the resulting embryo transferred to a woman’s uterus
- Includes use of donor eggs
- Includes use of a surrogate
- Fertility drugs - even if the does not provide prescription drug benefits
- Ovulation induction - the use of drugs to stimulate the production of follicles and eggs
- Surgery
- Microsurgical sperm aspiration - procedure used to extract sperm for use in ICSI
Infertility Treatments Exempt from NJ Mandate
Certain procedures are specifically excluded from the mandate. Reversal of voluntary sterilization is not covered: vasectomy reversal, and tubal ligation reversal. Partners of anyone who underwent a successful sterilization reversal may not be excluded. All other persons undergoing a sterilization reversal will need to pay these costs out of pocket.
Medical payments for a surrogate during any ensuing pregnancy are not covered, unless the surrogate is a member of the same plan. The costs of cryopreservation, sperm, embryo, egg storage, non medical costs, experimental treatments, ovulation and sperm testing kits are not included in the mandate. IVF, GIFT, and ZIFT procedures are not covered until all reasonable and less expensive options have been used. Any person over the age of 46 is not covered.
Source: NJ Benefit Standards for Infertility Coverage
Medical payments for a surrogate during any ensuing pregnancy are not covered, unless the surrogate is a member of the same plan. The costs of cryopreservation, sperm, embryo, egg storage, non medical costs, experimental treatments, ovulation and sperm testing kits are not included in the mandate. IVF, GIFT, and ZIFT procedures are not covered until all reasonable and less expensive options have been used. Any person over the age of 46 is not covered.
Source: NJ Benefit Standards for Infertility Coverage
