Coverage Mandate 1:
Group health benefit plans that provide pregnancy-related benefits must offer coverage for services and benefits on an expense incurred, service, or prepaid basis for outpatient expenses that arise from in vitro fertilization procedures. Tex. Ins. Code Ann. § 1366.003(a).The benefits for in vitro fertilization procedures must be provided to the same extent as benefits provided for other pregnancy-related procedures. Id. § 1366.003(b).
Scope of Mandate 2:
Applies to group health benefit plans that provide benefits for hospital, medical, or surgical expenses incurred as a result of accident or sickness. This includes group health insurance policies, health care service contracts or plans, or other provisions of group health benefits, coverage, or services provided by: an insurer; a group hospital service corporation; an HMO; or an employer, union, association, or self-insured benefit program. Tex. Ins. Code Ann. § 1366.001.Health benefit plans issued by a health carrier through a health group cooperative are not required to offer in vitro fertilization coverage. 28 Tex. Admin. Code § 26.409(a)(1).
Coverage Cap 3:
Requirements or Limitations on Coverage 4:
To qualify for coverage, all of the following requirements must be met:
- The patient for the in vitro fertilization procedure must be an individual covered under the group health benefit plan; and
- The fertilization or attempted fertilization of the patient's oocytes must be made only with the sperm of the patient's spouse; and
- The patient and the patient's spouse must have a history of infertility for at least 5 continuous years or the infertility is associated with: endometriosis, exposure in utero to diethylstilbestrol, blockage of or surgical removal of one or both fallopian tubes, or oligospermia; and
- The patient has been unable to attain a successful pregnancy through any less costly applicable infertility treatments for which coverage is available under the group health benefit plan; and
- The in vitro fertilization procedures must be performed at a medical facility that conforms to the minimal standards for programs of in vitro fertilization.
Yes, for religious organizationsInsurer, HMOs, and self-insuring employers that are owned by or part of a group directly affiliated with a bona fide religious denomination that finds in vitro fertilization to be contrary to its essential moral principles or beliefs are not required to offer coverage for in vitro fertilization. Tex. Ins. Code Ann. § 1366.006.
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.