Educate Yourself About State Mandated Infertility Insurance Coverage

If you have been diagnosed with infertility and are lucky enough to live in one of the following 15 states, I have good news for you. Currently only Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia have state laws mandating the coverage of some form of infertility testing and/or treatment. This could be your way to pay for infertility testing or treatment, but you need to know the details before you bet your bank account on it.

First, you need to know what kind of insurance plan your or your partner's business has. In all of the above 15 states, businesses that self-insure are exempt from the law. A self-insure health care plan is basically insurance that is paid for and operated by the business instead of being purchased from an insurance company. This does not mean that infertility will not be covered by a business that self-insures, only that they are not required to cover infertility under the current state mandate.

If your health care policy is not a self-insure policy, and you live or work in one of the 15 states above, congratulations, your chances of having some infertility coverage has increased greatly. However, there are other exemptions, which vary from state to state, but here is a grouping of the most common exemptions and which states they are valid in.

1.Does not cover IVF – California, Louisiana, and New York
2.Not required to provide coverage if there are fewer than 50 employees – Maryland and New Jersey *Illinois has a threshold of 25 or fewer employees
3.Religious organizations are not required to cover infertility – California, Connecticut, Illinois, Maryland, New Jersey, and Texas

There are more exclusions in some states, and the best thing you can do is educate yourself not only on what your health care policy states is covered, but also on what the state law says is and is not covered for your state. If while reading your policy and comparing it to the state law you find that the insurance states it will not cover something that the state law says it must cover, you need to contact a patient advocate with your insurance company.

Have all of your facts ready and on hand. That means that you need to have your health care policy open to the page(s) that deal with infertility coverage as well as information either on your computer screen or printed out that states what the state law is for your state. An excellent resource is Resolve's information on current state laws at http://www.resolve.org/site/PageServer?pagename=lrn_ic_stintro

Once you have your information and are ready, call your insurance company and ask to speak to someone in patient resources or a patient advocate. Explain to the person what you learned about your state law and what the insurance policy is telling you. Do not get angry or threatening in any way, you are talking to them to learn if the policy has any errors in it, as that could be the case. Be sure to get the name of the person you are talking to as you may need this information later.

If after talking to your insurance company they still state that they are not covering any testing or procedures that the state law says must be covered, you then need to contact either your state Attorney General or your state's Insurance Commission to have them investigate if your insurance company is breaking the state law. It is possible that you will need to have the testing or procedure done and have the insurance company refuse to cover it before you can take any action, so be prepared to fight.

All information contained in this web site is for informational purposes only.
Do not consider the information herein to be of a diagnostic nature.
Always consult your health care professional if you have any health concerns.