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California

Coverage Mandate 1:

Yes

Effective 1/1/1990.

California law requires insurers and health care service plans to offer coverage of infertility treatment, except IVF. Cal. Health & Safety Code § 1374.55; Cal Ins. Code § 10119.6. With respect to HMOs, this only applies to group contract holders with at least 20 employees to whom the plan is offered.

“Infertility” means either (1) the presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or (2) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception. Cal. Health & Safety Code § 1374.55(b); Cal Ins. Code § 10119.6(b).

“Treatment for infertility” means procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Id.

“In vitro fertilization” means the laboratory medical procedures involving the actual in vitro fertilization process. Id.

Scope of Mandate 2:

 

Coverage Cap 3:

 

Requirements or Limitations on Coverage 4:

To meet the definition of “infertility,” the patient must have:

  • the presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or

  • the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.

Cal. Health & Safety Code § 1374.55(b); Cal Ins. Code § 10119.6(b).

The plan must “offer”: procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer (not including IVF). Id.

Exemptions 5:

Yes, for religious organizations

The law does not require any plan that is a subsidiary of an entity whose owner or corporate member is a religious organization, to offer coverage for treatment of infertility in a manner inconsistent with that religious organization's religious and ethical principles. Cal. Health & Safety Code § 1374.55(f); Cal. Ins. Code § 10119.6(f).   “Subsidiary” is defined to mean “a corporation more than 45% of the voting power of which is owned directly, or indirectly through one or more subsidiaries, by the specified corporation.” Id.

Fertility Preservation: 

Yes

“When a covered treatment may directly or indirectly cause iatrogenic infertility, standard fertility preservation services are a basic health care service” Cal. Health & Safety Code § 1374.551.

“Iatrogenic infertility” means infertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment.

“May directly or indirectly cause” means medical treatment with a possible side effect of infertility, as established by the American Society of Clinical Oncology or the ASRM.

“Standard fertility preservation services” means procedures consistent with the established medical practices and professional guidelines published by the American Society of Clinical Oncology or the ASRM.

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.
ReproductiveFacts.org
is a patient education website of ASRM.
 

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For more information

  • If you have questions about insurance laws in your state or territory, please call your state or territory's Insurance Commissioner's office.
  • To learn about pending legislation in your state or territory, please contact your State or Territory Representatives.

The Employment Retirement Income and Security Act of 1974 exempts companies that self-insure from state regulation.