Menu

New Jersey

Coverage Mandate 1:

Yes

Effective Nov. 29, 2001

The mandate to cover medically necessary expenses incurred in the diagnosis and treatment of infertility applies to:
  • All policies, contracts, riders and endorsements delivered, issued, executed or renewed in NJ by health service corporations, hospital service corporations, medical service corporations and health insurance companies for groups other than small employers (meaning over 50 employees) that provide hospital or medical benefits, including pregnancy-related benefits
  • All contracts and evidence of coverage forms issued by HMOs for groups of over 50 employees that include pregnancy-related coverage
  • All group policies in this state for groups over 50 employees that offers hospital or medical benefits, including pregnancy-related benefits
  • N.J. Admin. Code § 11:4-54.1(c)
Infertility means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or any one of the following conditions:
  1. A male is unable to impregnate a female;
  2. A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
  3. A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
  4. A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
  5. A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
  6. Partners are unable to conceive as a result of involuntary medical sterility;
  7. A person is unable to carry a pregnancy to live birth; or
  8. A previous determination of infertility pursuant to this section.

Infertility resulting from voluntary sterilization procedures are excluded from coverage.

Must be less than 46 years of age.

The patient has been unable to obtain successful pregnancy through any less costly infertility treatments covered by insurance.

“Iatrogenic infertility” means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

“Standard fertility preservation services” means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health.

Scope of Mandate 2:

The policy shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination (unlimited cycles); gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; ovulation induction; assisted hatching; and four completed egg retrievals per lifetime of the covered person.
NJ Rev. Stat. §§ 17:48-6x; 17:48A-7w; 17:48E-35.22; 17B:27-46.1x (2017); N.J. Admin Code § 11:4-54.2

Implementing rules do not apply to any insurance policies available to individuals eligible for state medical assistance, including NJ Medicaid, the Children’s Health Care Coverage program, the FamilyCare Health Coverage Program. N.J. Admin. Code § 11:4-54.1(c)

Coverage Cap 3:

No

Requirements or Limitations on Coverage 4:

Group insurers, HMOs, State Health Benefits Program, and School Employees Health Benefits Program that provide pregnancy related coverage must provide infertility treatment including, but not limited to:
  • artificial insemination;
  • assisted hatching;
  • diagnosis and diagnostic testing;
  • fresh and frozen embryo transfers;
  • 4 completed egg retrievals per lifetime;
  • IVF, including IVF using donor eggs and IVF where the embryo is transferred to a gestational carrier or surrogate;
  • ICSI;
  • GIFT;
  • ZIFT;
  • medications;
  • ovulation induction; and
  • surgery, including microsurgical sperm aspiration; and
  • standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility.
The procedures must be performed at facilities that conform with ACOG and ASRM guidelines.

Exemptions 5:

Employers with fewer than 50 employees do not have to provide coverage.

Cryoperservation is not covered except for those at risk of iatrogenic infertility.

Nonmedical costs of egg or sperm donor are not covered.

Infertility treatments that are experimental or investigational are not covered.

Does not include the storage of sperm or oocytes.

Does not require religious employers to cover infertility treatment.

Employers who self-insure are exempt from the requirements of the law.

Fertility Preservation: 

Yes.

The mandate to provide standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility applies to
  • Hospital, medical and health service corporation contracts providing hospital or medical benefits to groups of 50+ persons
  • Every contract purchased by the State Health Benefits Commission
  • Every contract purchased by the School Employees’ Health Benefits Commission
Iatrogenic infertility means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

“Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the NJ Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes.

NJ Rev. Stat. §§ 17:48-6rr; 17:48A-7oo; 17:48E-35.42 (2019).

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.
 

RFSubscribe.jpg

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.