In 2021 the Department of Health (DOH) completed a mandated benefit sunrise review of a proposal to mandate coverage for fertility services. ?The proposal required health plans, including plans offered to public employees, to provide coverage for standard fertility preservation services, the diagnosis of infertility, and treatment for infertility, including four completed oocyte retrievals with unlimited embryo transfers. ?The DOH found that health plans generally did not include coverage for fertility treatments, that out-of-pocket costs for these services are generally expensive, and that the mandated benefit would likely result in increased costs to the state, health carriers, and enrollees, but may decrease out-of-pocket costs for patients and allow for better quality care and informed decision-making.?
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The 2022 Supplemental Operating Budget included a proviso requiring the Insurance Commissioner (Commissioner), in consultation with the Health Care Authority (HCA), to complete an analysis of the cost to implement a fertility benefit as described in the 2021 mandated benefit sunrise review. ?The Implementation Cost Analysis, provided by Milliman and published June 30, 2023, analyzed five benefit categories (infertility diagnosis, non-assisted reproductive technology treatments, assisted reproductive technology treatments, fertility preservation for patients with medically induced fertility, and fertility medication) and estimated a per-member per-month cost of these categories of coverage to the different types of health plans.?
Group health plans, including health plans offered to public employees and their covered dependents, issued or renewed on or after January 1, 2026, must include coverage for standard fertility preservation services. ?Plans issued or renewed on or after January 1, 2027, must include coverage for the diagnosis of and treatment for infertility, which must include two complete oocyte retrievals with unlimited embryo transfers in accordance with the American Society for Reproductive Medicine's guidelines, using single embryos when medically appropriate. ?The health plans may not include any:?
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The HCA must provide coverage for standard fertility preservation services for Medicaid enrollees. ?The HCA and Medicaid managed care organizations may not include: ?any exclusions or limitations on coverage of fertility medications different than those imposed on other prescription medications; or benefit maximums, waiting periods, or other limitations on coverage for these services that are different from those imposed upon benefits for other services.
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For purpose of these requirements, "diagnosis of and treatment for infertility" means the recommended procedures and medications from the direction of a licensed physician that are consistent with established, published, or approved medical practices or professional guidelines from the American College of Obstetricians and Gynecologists or the American Society for Reproductive Medicine. ?"Standard fertility preservation services" means procedures that are consistent with the established medical practices or professional guidelines published by the American Society of Reproductive Medicine or the American Society of Clinical Oncology for a person who has a medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.?
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"Infertility" means a disease, condition, or status characterized by:?
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The Commissioner is authorized to adopt rules to implement, administer, and enforce the provisions related to health carriers. ?This act may be known and cited as the Washington State Building Families Act.