The Connecticut state infertility insurance law mandates that “certain individual and group health policies to cover medically necessary costs of diagnosing and treating infertility.” Coverage for IVF is mandated with limits.
Like any regulation, the devil is in the details. Not every CT resident who is trying to conceive is assured of having every infertility treatment procedure covered by insurance.
There are several important points to know:
- What are the key requirements and definitions?
- What are the limits and exclusions?
- How does Obamacare affect the law?
Connecticut Infertility Coverage Mandate
The Connecticut state infertility insurance mandate has broad coverage requirements.
The law is “applicable to individual and group health policies that cover basic hospital expenses; basic medical-surgical expenses; major medical expenses; hospital or medical service plans contracts; and, hospital and medical coverage provided to subscribers of a health care center that are delivered, issued, amended, renewed or continued on or after October 1, 2005”.
The Connecticut state infertility insurance mandate defines infertility as “the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.”
The law provides that covered medically necessary expenses of the diagnosis and treatment of infertility include, but are not limited to the following.
- Ovulation induction up to 4 cycles
- Intrauterine insemination up to 3 cycles
- Uterine embryo lavage
- Embryo transfer
- Gamete intra-fallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
- Low tubal ovum transfer
The CT infertility mandate contains limitations that carriers can impose on plan benefits. There is one other potentially large hole: the act mandates that plans carriers determine medical necessity.
Managed Care Providers
Managed care organizations (HMO and/or PPO) may confine benefits to in-network providers only. This means you must find a fertility clinic that accepts your specific health plan. Otherwise, you must pay the entire cost must out of pocket.
Specific infertility treatment costs are not included in the mandate such as sperm and egg donor costs, expenses related to any resulting pregnancies and deliveries that may result, reversal of sterilizations such as tubal ligation and/or vasectomies, gestational carriers, and surrogate arrangements.
Short-term disability in Connecticut helps with the resulting pregnancies and deliveries by replacing mom’s income during maternity leave. Purchase prior to conception in order to qualify.
Carriers may institute a separate tier for prescription fertility drugs. Many plans have a tiered plan with varying copay and coinsurance amounts: generics, preferred, and name brand tiers are most common. The allowable range for copays is up to $40, and coinsurance can go as high as 50%. Given the cost of many fertility drugs, you might expect to see coinsurance used more heavily as this costs the insurer less – but you far more.
The CT State infertility insurance law has exclusions that may apply to certain residents. It applies only to women up to age 40.The exclusions fall into three categories: membership qualifications, religious organizations, and out of state headquartered employers.
You must have been a member of your plan for at least twelve months before infertility treatments are covered. That means shopping around for a new plan requires that you wait before starting your next procedure. In addition, any infertility procedures performed in the past must be disclosed to your new carrier.
Any religious organization is entitled to opt out of coverage if the methods of diagnosing and treating infertility are contrary to their moral values. The carrier would then issue a rider to the policy excluding infertility coverage.
Out of State Employer Headquarters
The law regulates health insurance companies, not employers. If you work for a large employer that self-insures, you may not be covered. Check with your HR department before undergoing infertility treatments.
Check the infertility insurance laws in other states. The law can only be enforced when Connecticut has jurisdiction to regulate. If your employer headquarters in another state, your health plan may not be subject to this mandate. If you commute into New York or Massachusetts then your insurance plan may be regulated by those state laws.
Connecticut In Vitro Fertilization Mandate
The Connecticut law also mandates insurance coverage for In Vitro Fertilization (IVF). The plan must provide lifetime benefits of two IVF cycles, limited to two embryo transfers per cycle.
The IVF benefit is limited to individuals who have been unable to conceive through other less expensive infertility treatments covered under the plan. Benefits are subject to preapproval by the carrier, leaving a large gray area of interpretation. When has the individual tried enough other alternative treatments before IVF benefits may be approved?
The law also requires disclosure from the covered individual of any IVF treatments that may have been covered under another plan. Changing plans to reset the lifetime limit does not appear to be a lawful maneuver.
Affordable Care Act
The Affordable Care Act is a federal law, which directly affects the Connecticut IVF mandate by making the leftover expenses more costly. While the essential health benefits raise the bar for what needs to be included in a plan, the need to make the coverage affordable means the larger deductibles, and co-insurance may result. IVF may be covered, but at a lower percentage than in the past.
The Affordable Care Act contained two provisions making these unreimbursed IVF expenses cost more. The threshold for deductible medical expenses was raised from 7.5% of Adjusted Gross Income (AGI) to 10.0%. In addition, limits were placed on the amounts that could be contributed to a Flexible Spending Account – $2,500 annually. Both provisions raise the after-tax cost of IVF treatments.
Maternity Leave Laws
Connecticut maternity leave laws also interact with the IVF mandate for coverage. Many couples undergoing IVF implant multiple embryos to increase the odds of conception and decrease the odds that they exhaust the two-cycle limit before getting pregnant.
This also increases the odds of multiple pregnancies, which often result in high-risk complications, extended bed rest, and a lengthy stay for two preemies in the Neonatal Intensive Care Unit (NICU).
This means one or both parents may need to take extended time away from the job. The added protections make IVF more affordable from the broadest perspective.
- CT Insurance Dept Bulletin HC-64
- Image credit: fambros / 123RF Stock Photo