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Rhode Island Infertility Mandate
Rhode Island Infertility& IVF Insurance Law
Rhode Island infertility and IVF insurance is available to some state residents.
The Rhode Island infertility health insurance law mandates that any health insurance contract, plan, or policy delivered or issued for delivery or renewed in Rhode Island, which includes pregnancy related benefits, shall provide coverage for medically necessary expenses of diagnosis and treatment of infertility for women between the ages of twenty-five (25) and forty-two (42) years.
Before beginning any infertility protocol make sure you understand:
- Who is covered
- What infertility treatments are covered
- Where the holes are - can you afford to spend $20,000 or more before getting pregnant?
- What to do next
Supplemental Insurance: Maternity Pay and More How long can you pay your regular bills with a 40% pay cut? Now add to that your left over costs trying to get pregnant while waiting for the RI infertility mandate waiting period to expire. Buy additional disability coverage before starting your next cycle. Increase your maternity leave income and worry less about the extra costs.
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Rhode Island Infertility Insurance - Who is Covered?
The Rhode Island infertility law covers employers of all sizes - unlike in other states. But that does not translate automatically into every plan having infertility coverage. The RI regulation applies to any policy “which includes pregnancy related benefits”. If your plan does not include pregnancy related benefits, it might be exempt from the requirement.
State insurance laws sometimes include requirements that health plans cover pregnancy either in the individual and/or small group market. Generally most medical plans won’t cover normal pregnancy unless required by law. Rhode Island does not require individual or small groups to cover normal pregnancy, so the requirement may leave a very big hole.
The Pregnancy Discrimination Act is a national regulation requiring group health plans with 15 or more employees to cover pregnancy in the same manner as any other covered illness. Therefore, if you work for a Rhode Island based employer with more than 15 employees, the chances are good that you have this coverage.
The RI mandate also applies exclusively to any policy “delivered or issued for delivery or renewed in this state”. If your employer is headquartered outside of Rhode Island, that plan does not need to comply with the mandate. Chances are your plan will not cover infertility. Fourteen other states have some type of infertility mandate requiring some level of coverage. Check the regulations in the headquarter state of both employers - yours and your spouses.
The law defines infertility as “married individual who is unable to conceive or sustain a pregnancy during a period of one year”. This clause excludes a wide swath of couples trying to conceive: unmarried couples, domestic partners, and civil unions are not included.
The law applies to “Any health insurance contract, plan, or policy”. If your employer self insures it may be exempt from these requirements.
RI Infertility Insurance Mandate - Where are the Holes?
The Rhode Island infertility insurance law requires that infertility treatments be covered. Lifetime benefits are capped at $100,000, and the law allows for 20% co-insurance. In other words, you may be faced with $20,000 of out-of-pocket expenses, or much more. There are a variety of ways the “or more” portion may play out.
If you consume the entire lifetime benefit, your plan may ask you to pay 20% of the “allowed charges” or up to $20,000. That part is most obvious. You may consume the entire benefit, and want to continue trying to get pregnant. 100% of the expenses are then your responsibility. Five IVF cycles could get you to this number.
Your infertility clinic may be out of network. Your plan pays for the allowed charges, but an out of network clinic charges whatever it wants. You are responsible for the difference between the clinic fees, and what your plan allows.
You may be taking fertility drugs. Insurance companies publish formularies - lists of prescription drugs which it will cover. If your doctor prescribes a drug not on your insurers formulary, you must pay the amount out of your pocket.
If you consume the entire lifetime benefit, your plan may ask you to pay 20% of the “allowed charges” or up to $20,000. That part is most obvious. You may consume the entire benefit, and want to continue trying to get pregnant. 100% of the expenses are then your responsibility. Five IVF cycles could get you to this number.
Your infertility clinic may be out of network. Your plan pays for the allowed charges, but an out of network clinic charges whatever it wants. You are responsible for the difference between the clinic fees, and what your plan allows.
You may be taking fertility drugs. Insurance companies publish formularies - lists of prescription drugs which it will cover. If your doctor prescribes a drug not on your insurers formulary, you must pay the amount out of your pocket.
