Ohio insurance law mandates infertility coverage by health insuring corporations as a basic health care service. The law classifies infertility under preventative health care services.
Like any regulation there are important definitions, limitations, and exclusions that may apply. Learn how the Ohio insurance law mandating infertility coverage works, and find alternative to lower costs.
- Key definitions of the mandate
- Health insuring corporations
- Basic health care service
- Limitations and exclusions
- Impact of the Affordable Care Act
Ohio Infertility Insurance Mandate Definitions
The Ohio insurance law mandating infertility coverage has multiple definitions that severely narrow the scope of the requirements. Although better than no requirement at all, the Ohio regulation is one of the least impactful state-based infertility mandates.
The law applies only to health insuring corporations, and classifies infertility treatment as a preventative basic health care service. The mandate requires treatment only when medically necessary. Look more closely at the definitions of each term: HMO, basic health care service, and medically necessary.
Health Insuring Corporations
The most important definition to understand under the Ohio infertility insurance law is the meaning of “health insuring corporation”. The language is dense and difficult to understand. Below are paraphrases of the most relevant definitions. With each definition comes the need for another.
A health insuring corporation means a corporation that provides basic health care services through either an open panel or closed panel system. An open panel system provides incentives for enrollees to utilize participating providers, but also allows enrollees to use non-participating providers. A closed panel system requires enrollees to use only providers that participate.
Health insuring corporations conforming to these rules are allowed to use the name Health Maintenance Organization or HMO.
The key point to understand with these definitions is that not every single form of health insurance meets this definition. It is quite possible that the plan you are enrolled in may not be subject to the mandate. Find help with infertility treatment costs using the tax code and supplemental insurance.
Basic Health Care Services
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
Ohio Infertility Insurance Mandate Exclusions
The Ohio insurance law mandating infertility coverage has exclusions that are clearly stated in the legal language and treatments that may be excluded by omission. Certain infertility procedures are specifically excluded from the mandated requirements:
- IVF – In Vitro Fertilization
- GIFT – Gamete Intrafallopian Transfer
- ZIFT – Zygote Intrafallopian Transfer
Experimental medical procedures are also explicitly excluded but not defined. The terms “medically necessary”, combined with “preventative health care services”, and combined with a short list of specifically mandated treatments means that many procedures fall into a gray area. Many treatments such as artificial insemination, fertility drugs, and more are not mentioned.
This leaves plenty of room for interpretation, and claims denials. Make certain you obtain a preauthorization for any medically necessary infertility treatment. Utilize zero interest infertility financing to help make the treatments more affordable.
Ohio IVF Insurance
As you have seen Ohio IVF insurance is not guaranteed under the mandate. It is unlikely that many insurance plans will volunteer to cover In Vitro Fertilization. Consider using supplemental health insurance for IVF instead. Benefits payments are made when IVF treatments succeed.
Impact of the Affordable Care Act
Understanding the impact of the Affordable Care Act (ObamaCare) on the Ohio infertility insurance mandate is very imprecise. The new federal regulation is very complex, and rules are being established as issues surface.
When a state-level mandate intersects with the federal law, the mandate continues only if the state agrees to cover the costs associated with premium and cost sharing subsidies. The status of the Ohio mandate is unclear at this time.
Increased Medical Expenses
One area of ObamaCare impact on infertility insurance in Ohio is the taxation of un-reimbursed medical expenses. Couples undergoing infertility treatments in Ohio face limitations based upon type of plan, and cause of their infertility. They may incur very high un-reimbursed medical expenses, especially if undergoing IVF.
Two ObamaCare provisions raise these costs. The medical deduction threshold was raised from 7.5% of adjusted gross income, to 10.0%. Also, the annual amounts employees can contribute to a flexible spending account were limited to $2,500. Both raise costs by limiting the tax savings on these expenses.
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