Ohio Infertility & IVF Health Insurance Laws

Ohio is one of only a handful of states with a law requiring certain insurance plans to cover infertility treatments. Some of the wording is vague and difficult to interpret. You will find below some of the important definitions and key points summarized below in simplified language. 

• The mandate may only apply to Health Maintenance Organizations (HMO)
• Any fertility treatments must be medically necessary
• Employers headquartered out of state need not comply

The Ohio mandate is not the most comprehensive or specific state law we have seen. Chances are not high that your plan will be required to cover all your costs when trying to conceive. You may need to pay out of pocket. Make sure you leverage the tax code to it’s fullest advantage, and use supplemental insurance to offset your costs when you become pregnant and deliver your baby.

Ohio insurance law mandates that a Health Insuring Corporation must provide basic health care services when medically necessary. In order to understand and apply this applies to OH couples trying to conceive, we must interpret each of these terms from some dense legal language.

A Health Insuring Corporation is defined as an entity that pays for health care services through an open panel or closed panel plan. Okay that really clears things up doesn’t it? A closed panel plan requires enrollees to use participating providers. An open panel plan also allows enrollees to use services from non participating providers. These are more commonly referred to as in network and out of network providers.

Other sites publishing information about this mandate have interpreted this language to mean that only Health Maintenance Organizations (HMO or closed panel plans) are subject to the mandate. The language we read suggests that other plan types are subject also - the open panel plans. We are not lawyers so read Ohio Revised Code 1751.01 for yourself. You decide what it means.

If the HMO interpretation is correct and your plan is a Preferred Provider Plan (PPO), Point of Service plan (POS), or traditional fee for service plan, chances are your infertility treatments are not covered. 

Basic health care services are defined in part as preventive services including fertility procedures. The Ohio Department of Insurance issued Bulletin 2009-07 clarifying the meaning of infertility services, and the phrase "medically necessary". Infertility services are defined as diagnostic and exploratory procedures to correct medically diagnosed diseases of the reproductive organs including but not limited to:

• Endometriosis - cells from the lining of the womb grow in other areas of the body
• Collapsed or clogged fallopian tubes 
• Testicular failure - testicles cannot produce sperm or male hormones

Certain infertility procedures are specifically excluded from the mandated requirements:

• IVF - In Vitro Fertilization
• GIFT - Gamete Intrafallopian Transfer
• ZIFT - Zygote Intrafallopian Transfer