Does the ACA require infertility treatment to be covered by health insurance?

Q: Does the ACA require infertility treatment to be covered by health insurance?

A. No. Treatment for infertility is not one of the ten essential benefits, and coverage for it is not mandated by the ACA or any other federal law. But that doesn’t mean it’s never covered, as states can have regulations that go beyond the minimum requirements laid out by the federal government.

State laws

Fifteen states have laws that require at least some coverage for infertility treatment: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia.

However, in California, Illinois, and Texas, coverage for infertility treatment is only required on group plans, and not on individual policies that people purchase on their own (but individual market plans sold in Illinois are required to include coverage for infertility because the state’s benchmark plan includes infertility coverage, and in Texas, the benchmark plan includes coverage for diagnosis — but not treatment — of infertility, so diagnosis of infertility is covered on individual market plans in Texas aswell; the interaction of benchmark plans and infertility coverage is discussed below).

In those 15 states, the mandated coverage varies quite a bit from one state to another. Some do not cover in vitro fertilization (IVF) or medications, some have specific diagnosis requirements or lifetime benefit maximums, others only require coverage on large group plans, and/or HMOs, etc.

Benchmark plans

A total of 23 states have a benchmark plan that includes some form of infertility treatment coverage (the benchmark plan in each state serves as the model for the minimum level of coverage that individual and small group plans in the state must provide; see definition number two).

Most of those states overlap with the states listed above that have laws requiring at least some coverage for infertility diagnosis and/or treatment. But several states without infertility coverage mandates are among the states where the benchmark plan includes at least some infertility coverage. They include: Arizona, Colorado, DC, Iowa, Michigan, Missouri, Nevada, New Hampshire, North Carolina, Pennsylvania, Tennessee, and Virginia.

But just as the state laws vary considerably, so do the coverage details in the benchmark plans. Some require coverage for treatment like IVF, GIFT, and ZIFT, while others specifically exclude those treatments. For example:

  • The benchmark plans in Arizona, DC, and Tennessee only include coverage for diagnosis of infertility.
  • The benchmark plans in Kansas, Michigan, Missouri, New Hampshire, Virginia, and West Virginia only include diagnosis of infertility and treatment of the underlying causes of infertility.
  • The benchmark plans in Montana, Nevada, New York, Pennsylvania, and Colorado only include diagnosis of infertility and artificial insemination.
  • The benchmark plans in Iowa and North Carolina only include diagnosis of infertility and medical stimulation of ovulation.
  • The benchmark plans in Connecticut, Hawaii, Illinois, Maryland, and Massachusetts all include more comprehensive coverage, including IVF (note that these are all states with laws requiring infertility coverage).

CMS provides details for each state’s benchmark plan, including the changes that some states made as of 2017.

CMS clarifies that those plans are effective “for plan year 2017 and beyond,” but new benchmark plans might be implemented in some states as of 2019. HHS has proposed changes to the rules that states use to establish their benchmark plans. If finalized as proposed, some states might end up with weaker benchmark standards (starting in 2019) than they’ve had for the first several years of ACA implementation. In some cases, this might result in infertility services no longer being covered, even if they were covered in prior years.

In cases where state law requires coverage for diagnosis and/or treatment of infertility, the benchmark plan (and thus, all of the new plans offered in the individual and small group markets) will continue to include that coverage.

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