Coverage Mandate 1:
The Public Employees’ Health Plan (effective 7/1/2020) and the Medicaid program (if waiver is approved; effective 5/12/) must provide coverage for in vitro fertilization services and genetic testing for individuals with genetic traits associated with certain heritable conditions who receive in vitro fertilization services. Utah Code Ann. §§ 26-18-420(3)(a)-(b), 49-20-420(2)(a)-(b).
Scope of Mandate 2:
Coverage Cap 3:
Requirements or Limitations on Coverage 4:
To qualify for coverage:
- The individual must be enrolled in the Medicaid program; and
- The individual must has been diagnosed by a physician as having a genetic trait associated with cystic fibrosis, spinal muscular atrophy, Morquio Syndrome, myotonic dystrophy, or sickle cell anemia; and
- The individual intends to get pregnant with a partner who is diagnosed by a physician as having a genetic trait associated with the same condition as the individual.
Yes, through the Medicaid program (if waiver is approved)
The Medicaid program (if waiver is approved) must provide coverage for standard fertility preservation services to individuals who: (i) are enrolled in the Medicaid program; (ii) have been diagnosed with a form of cancer by a physician; and (iii) need treatment for that cancer that may cause a substantial risk of sterility or iatrogenic infertility. Utah Code Ann. §§ 26-18-420.1(1)(c), 26-18-420.1(3).
“Standard fertility preservation service” means a fertility preservation procedure that is not considered experimental or investigational and is consistent with established medical practices or professional guidelines. This includes sperm banking, oocyte banking, embryo banking, banking of reproductive tissues, and storage of reproductive cells and tissues. Id. § 26-18-420.1(1)(d).“Iatrogenic infertility” means an impairment of fertility or reproductive functioning caused by surgery, chemotherapy, radiation, or other medical treatment. Id. § 26-18-420.1(1)(a).
“Qualified assisted reproductive technology cycle” means the use of assisted reproductive technology to transfer a single embryo for implantation. “Assisted reproductive technology” means all treatments or procedures which include the handling of human oocytes or embryos, including in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer. Id. § 49-20-418(1)(d); 42 U.S.C. § 263a-7.
The pilot program will end plan year 2023-24. Utah Code Ann. § 49-20-418(2)(a).
The purpose of the pilot program is to study the efficacy of providing coverage for the use of an assisted reproductive technology and is not a mandate for coverage of an assisted reproductive technology within all health plans offered by the program. Id. § 49-20-418(5)(a).
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.