District of Columbia
Coverage Mandate 1:
Beginning January 1, 2025, all health insurers offering an individual, small group, or large group health benefit plan must provide coverage for the diagnosis and treatment of infertility, including the following:
- Three rounds of IVF
- Standard fertility preservation services.
- At least 3 complete oocyte retrievals with unlimited embryo transfers from those oocyte retrievals or from any oocyte retrieval performed prior to January 1, 2025.
- The medical costs related to an embryo transfer to be made from an enrollee to a third-party; except, that the enrollee’s coverage shall not extend to any medical costs of the surrogate or gestational carrier after the embryo transfer procedure.
Beginning January 1, 2024, the DC Healthcare Alliance program shall provide health insurance coverage for the diagnosis of infertility and any medically necessary ovulation enhancing drugs and medical services related to prescribing and monitoring the use of such drugs, which shall include at least 3 cycles of ovulation-enhancing medication treatment over an enrollee’s lifetime. By January 1, 2024, the Department of Health Care Finance will submit an amendment to the Medicaid state plan to the Centers for Medicare & Medicaid Services (CMS) that would authorize coverage through Medicaid for the diagnosis of infertility and any medically necessary ovulation enhancing drugs and medical services related to prescribing and monitoring the use of such drugs, which will include at least 3 cycles of ovulation-enhancing medication treatment over an enrollee’s lifetime. Within 180 days of the effective date of this section, the Department of Health Care Finance shall submit a report to the Council after consulting with CMS on whether in vitro fertilization and standard fertility preservation services are medically reasonable and necessary procedures under federal law, possible methods for covering in-vitro fertilization and standard fertility preservation services as a Medicaid covered benefit for both fee-for-service and managed care organizations, including any potentially applicable waiver authorities, and the amount of money that would need to be allocated to federal and local funds for such coverage.
Scope of Mandate 2:
Coverage Cap 3:
Requirements or Limitations on Coverage 4:
Exemptions 5:
Fertility Preservation:
Notes
1 Does the state have a coverage mandate, Y/N. Include effective date of the mandate. Specify if the mandate is to “offer” services or to “cover” them.
2Which insurers are required to comply with the mandate. If not applicable, put N/A.
3Is there a cap (annual/lifetime)?
4Does the law impose age restrictions on eligibility for coverage? Does it limit the number of IVF cycles covered (or require at least a certain number of services be covered)? Does it mandate a waiting period? Other limitations? How is “infertility” defined? Is it inclusive (e.g.: does it apply only to married or -opposite sex couples, or is it inclusive?)
5What, if any, exemptions apply to coverage under the mandate? For example: an exemption for small businesses or religious organizations.
