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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. But that doesn’t mean it’s never covered.

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.

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, etc.

Benchmark plans

In addition to state laws requiring some sort of coverage for infertility treatment, there are 19 states that 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; definition number two).

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.

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