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 the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, as well as four completed oocyte retrievals with unlimited embryo transfers.  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.
 
The 2022 Supplemental Operating Budget included a proviso requiring the Office of the Insurance Commissioner (OIC), in consultation with the Health Care Authority, to complete an analysis of the cost to implement a fertility treatment benefit as described in the 2021 mandated benefit sunrise review.  OIC contracted with Milliman to conduct the actuarial analysis and the report provided projections for the total cost and per member per month cost for implementing the benefits across different health insurance markets. 

Beginning January 1, 2026, group health plans, including health plans offered to public employees, must include coverage for standard fertility preservation services and beginning January 1, 2027 these plans must include coverage for the diagnosis of and treatment for infertility. This coverage must provide for two completed oocyte retrievals with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine. 

Coverage may not include:

• any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on other prescription medications;
• any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party; or
• any deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage that are different from those imposed upon benefits for services not related to infertility. 

Medicaid must provide coverage for standard fertility preservation services and coverage may not include:

• any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on other prescription medications; or
• any benefit maximums, waiting periods, or any other limitations that are different from those imposed upon benefits for services not related to infertility. 

For the purposes of this act, "Diagnosis of and treatment for infertility" means the recommended procedures and medications from the direction of a licensed physician or osteopathic 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. 

PRO: There is a great need for this type of coverage and its not broadly available among health plans. Infertility is a disease that should be covered by insurance. Fertility treatments should not be considered elective. The cost could be as low as 19 cents per member per month. The ability to have a family should not be dependent on what kind of insurance you have. 

CON: The proposal is very expensive and will make insurance even more out of reach. IVF is unethical because it can lead to destroying embryos.  

OTHER: Coverage is not applied consistently across all insurance markets. This would result in significant premium increases.