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 the disease or condition that results in the abnormal function of the reproductive system such that a person is not able to:

  • impregnate another person;
  • conceive after two years of unprotected intercourse if the female partner is under 35 years of age, or one year of unprotected intercourse if the female partner is 35 years of age or older or one of the partners is considered medically sterile;
  • or carry a pregnancy to live birth.
  • Infertility does not mean a person who has been voluntarily sterilized, regardless of whether the person has tried to reverse the sterilization.

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

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:

The insurer may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who:

  • has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy;
  • has not reached the limit of four completed egg retrievals; and
  • is 45 years of age or younger.

Infertility services shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

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

A carrier shall not impose a separate copayment, coinsurance, deductible, dollar maximum, visit maximum, or procedure maximum, except infertility coverage may be limited to four completed eff retrievals per lifetime of the covered person.

A carrier shall not impose a separate preauthorization notice or other utilization management requirement on infertility treatment.

N.J. Admin. Code. § 11:4-54.3

Exemptions 5:

Yes, religious employers

A religious employer may request, and a health service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer and intracytoplasmic sperm injection, if the required coverage is contrary to the religious employer's bona fide religious tenets.

"Religious employer" means an employer that is a church, convention or association of churches or any group or entity that is operated, supervised or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3)

NJ Rev. Stat. §§ 17:48-6x; 17:48A-7w; 17:48E-35.22; 17B:27-46.1x (2017).

Yes, benefit exclusions

The only permissible benefit exclusions are the following:

  • Reversal of voluntary sterilization
  • Surrogacy where the surrogate is not covered by the carrier’s policy or contract
  • Cryopreservation
  • Nonmedical costs of an egg or sperm donor
  • Experimental or investigational infertility treatments
  • Ovulation kits and sperm testing kits
  • IVF, gamete and zygote intrafallopian tube transfer for persons who have: not used all reasonable less expensive and medically appropriate treatments for infertility; who have exceeded the limit of 4 covered completed egg retrievals; or who are older than
  • Policies covered by this section may exclude infertility benefits if infertility medication benefits are provided under another policy issued to the same policyholder
N.J. Admin. Code § 11:4-54.5

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

Act effective 2001 as Public Law 2001, Ch. 236; Implementing regulations updated frequently – latest update year indicated in citation.

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.