Ohio insurance law mandates infertility coverage by health insuring corporations as a basic health care service.
What do “health insuring corporation,” and “basic health care service” mean in practical terms? The lawmakers do not make it easy!
The law classifies infertility under preventative health care services. Learn how the Ohio insurance law mandating infertility coverage works, and find an alternative to lower costs.
- Key definitions of the mandate
- Limitations and exclusions
- Tax code for government grants
Ohio Infertility Insurance Mandate Definitions
The Ohio insurance law mandating infertility coverage has multiple definitions that severely narrow the scope of the requirements. The law applies only to health insuring corporations and classifies infertility treatment as a preventative basic health care service.
Short-term disability in Ohio replaces income when the treatments succeed. Couples can take advantage with or without a legal requirement.
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. Health insuring corporations conforming to these rules are allowed to use the name Health Maintenance Organization or HMO.
- 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.
Ohio health insurance with maternity coverage may not fall under the mandate. Not every single form of coverage meets this definition.
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.”
Ohio maternity leave regulations may provide job security while undergoing treatments.
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 state insurance law mandating infertility coverage in Ohio 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
The law explicitly excludes but does not define experimental medical procedures. 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, reversal of voluntary sterilizations, 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.
Health insurance plans contain varying cost-sharing components. For example, deductibles, coinsurance, and copayments often leave policyholders with large medical bills – even when the plan covers the treatment. Keep these factors in mind when projecting costs.
Ohio IVF Insurance
As you have seen Ohio IVF insurance is not guaranteed under the mandate. It is unlikely that many plans will volunteer to cover In Vitro Fertilization.
The average cost of IVF in Ohio mirrors the rest of the country, except when your medical plan covers testing and other preliminary therapies.
Infertility and IVF Grants
Ohio state and federal tax regulations provide hidden infertility and IVF grant opportunities. Two different tax vehicles allow for significant levels of government assistance in three areas:
- State income taxes
- Federal income taxes
- FICA taxes
Flexible Spending Accounts work best as entry-level infertility grants. Each prospective parent can contribute $2,500 annually into an FSA. Use of pretax contributions reduces state, federal, and FICA expenses.
Taking deductions on Schedule C can work best as an IVF grant. Prospective parents see no savings on the first 10% of adjusted gross income, but expenses above this threshold amount yield significant savings, with modest limitations.
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.