We did it!! RESOLVE New England (of which I’m a board member) and Fertility Within Reach partnered up to get an infertility insurance mandate passed into law in New Hampshire. Thousands more New Hampshire residents now have access the fertility care. Yahoo for New Hampshire!!
Infertility Insurance Basics:
What does this infertility insurance mandate cover?
This law, RSA 417-G, covers three separate segments of fertility care:
- Infertility diagnostics (to figure out why you are not getting pregnant)
- Fertility treatment (to get you pregnant)
- Fertility preservation (to preserve your eggs or sperm before you undergo chemotherapy or another fertility-impairing medical procedure)
When does this law go into effect
The law takes effect on January 1, 2020, on a rolling basis as insurance policies are renewed (although many renew effective January 1st).
Does this law apply to all types of insurance?
The law applies to group health insurance plans. Group health insurance plans are the kind you purchase through your employer. But, there’s an important caveat here: Some New Hampshire employers offer “self-funded” health plans for their employees. Self-funded health plans are not a type of insurance. Self-funded plans are not subject to the requirements of this law (there’s a federal law that prohibits the State of new Hampshire from imposing requirements upon self-funded plans, so that just simply wasn’t possible). Also exempt are two uncommon types of health plans: SHOP plans and Extended Transition to Affordable Care Act Compliant Policies.
What can I do if I have a self-funded plan through my employer?
You can ask that the company voluntarily match the fertility care benefits under the mandate. Please contact Fertility Within Reach for more information about advocating with your employer for benefits.
What about individual health insurance plans?
Individual health plans–such as those purchased on the ACA Marketplace–are not covered by this law. The individual insurance market is very fragile and legislators felt it was unworkable to impose the requirements of this law on individual health plans.
I live in Vermont but my employer is based out of New Hampshire. Am I covered under this law?
You may be. Check with Human Resources to see if the company has a New Hampshire insurance plans. Typically, a company will purchase insurance through the location of its headquarters.
Diagnosis of Infertility:
What do I need to do to qualify for infertility diagnostic care?
Coverage for the diagnosis of infertility is offered to both men and women who have been diagnosed with infertility.
How is infertility defined for diagnostic purposes?
Infertility is defined as a disease, caused by an illness, injury, underlying disease, or condition, where a woman’s ability to become pregnant or to carry a pregnancy to live birth is impaired, or where man’s ability to cause pregnancy and live birth in his partner is impaired. This definition covers both male and female infertility.
Are a certain number of attempts at trying to conceive required before insurance coverage kicks in? How many months do we have to try at home first? How does that work?
The definition of infertility does not require attempting to conceive on your own for a set period of time. The reason is that time limits are only appropriate in situations where there is no known cause of infertility. It’s pointless to make a woman born without a uterus have 12 cycles of unprotected intercourse with her husband before she can receive treatment, for example. In cases where there is no known cause of infertility, insurance companies may impose medically-based time frames before the diagnostic procedures will be covered by the law.
We are a married lesbian couple. Our insurance company is telling us we have to pay out-of-pocket for 12 “supervised” IUIs using donor sperm before we can receive insurance benefits. Is that right? The IUIs plus the costs of the donor sperm add up quickly. What can we do to challenge this?
The law provides that lesbian couples may not be subject to different requirements than opposite-sex couples. (Presumably, opposite-sex couples are not subject to this requirement of 12 supervised IUIs.) You should know that the law does not specify what kind of pre-qualification requirements would be appropriate to impose upon same-sex couples. It’s up to the insurance companies to appropriately figure out how to meet this legal standard. If you believe your insurance company is falling short of meeting this legal standard, please reach out to me so we can set up some time to talk about your options.
Are gay couples covered by the law?
Yes. Infertility is not just a female problem. Guys can be infertile too! Your fertility doctor will run some routine tests to assess whether your sperm’s ability to cause pregnancy and live birth in a woman is impaired. Check out these Surrogacy FAQs to learn more about how surrogacy works under this insurance mandate.
Are single women covered by the law?
Yes, if you are diagnosed with infertility. The insurance companies have leeway to impose pre-qualification requirements regarding your “exposure to sperm.” These requirements cannot be more onerous than the requirements imposed upon married women. If you believe your insurance company is failing to meet this legal standard, please reach out to me to set up some time to talk about your options.
Fertility Treatment:
What kinds of fertility treatment are covered under this new law?
The law provides coverage for all non-experimental fertility treatments. This includes treatments such as in vitro fertilization (IVF), IUI, ovulation induction, surgerical interventions, and medications. The medical expenses portion treatments for donor eggs, donor sperm, and donor embryos (“embryo adoption”) are all covered. Experimental fertility treatments are just that–experimental–and not yet ready for mainstream medicine. Experimental fertility treatments are not covered. An example of a currently experimental fertility treatment is uterus transplantation.
Is there a maximum age for IVF benefits under this new law?
There is no set age limit in the law, because that would arbitrarily determine who does and does not receive coverage. IVF coverage decisions are made based on medical factors only, which may include consideration of the woman’s FSH and AMH levels. Unfortunately, traditional IVF is not an appropriate treatment for many women in their 40s, as the likelihood of a live birth resulting is too low. These women should talk to their doctors about whether they are appropriate candidates for egg donation or embryo donation (“embryo adoption”), instead.
How many cycles of IVF are covered under this law?
There is no maximum limit on the number of cycles that must be covered. This does not mean that an unlimited number of IVF cycles must be paid for. Rather, it means that limits cannot be based on arbitrary factors, and must instead be based on medical criteria and the patient’s own medical history.
Are donor eggs covered?
Yes!! The medical expenses related to donor egg treatment are covered– this includes screening, medication, monitoring, egg retrieval. This applies both to known and anonymous arrangements.
Are there any donor egg expenses I will have to pay out of pocket?
Non-medical expenses are always your out-of-pocket responsibility. Examples would be: the donor’s compensation, the agency’s fee, travel expenses for the donor, legal fees. You may be able to deduct some of these out-of-pocket costs on your federal tax return–please discuss this with your tax professional.
Is sperm donation a covered treatment?
Yes, sperm donation is covered. This includes both anonymous sperm bank arrangements and known donor arrangements. Please be aware that only medical expenses related to donor sperm are covered.
Are lesbian couples using donor sperm covered?
Yes, provided that you have a diagnosis of infertility, meaning that your ability to become pregnant or to carry a pregnancy to live birth is impaired (see above for what that means in the context of a lesbian relationship).
Is gestational surrogacy covered under this law?
Yes. Intended Parents pursuing gestational surrogacy are able to receive certain insurance benefits such as making embryos. Embryo transfers to a gestational carrier are not mandated coverage. For more information, check out these FAQs geared specifically towards surrogacy and insurance coverage.
Fertility Preservation:
Help! I was just diagnosed with breast cancer and am having surgery tomorrow. I will start chemotherapy a few weeks later. I have the opportunity to undergo fertility preservation through egg freezing before I start chemo. Does this infertility insurance law apply to women who need to freeze eggs before starting chemo?
Yes. This is exactly the type of situation that was contemplated in creating this fertility preservation benefit.
What about a man who is about to start chemotherapy for cancer? Can a man freeze his sperm?
Yes. Many people think the sperm preservation process is easy, but there are actually a bunch of logistical steps involved. These steps are covered up through the initial storage period.
What about storage costs for cryopreserved eggs and sperm?
Insurance companies must, at a minimum, cover short-term storage costs until the insurance policy term ends. Beyond that, long-term storage is the responsibility of the patient. The good news is that there are grants out there to help with storage costs. Check out Fertility Within Reach and New England Surrogacy’s resource page.
I’m not quite ready to have kids yet, mostly because I haven’t yet met the right guy. But I’m 32 and I know my fertility will soon be taking a hit. So I’d like to freeze my eggs for later use. Will this be covered?
Fertility preservation, including egg freezing, for non-medical reasons is not covered. If you have a medical reason for needing to preserve your eggs, such as premature ovarian insufficiency (POI), then you might be able to receive insurance benefits.
I’m going to be transitioning from male to female gender. I’d like to freeze some of my sperm before I undergo the transition process. Is this covered under the new law?
As long as your transition involves a medical treatment with a risk of impairment of fertility (and most do!), you can qualify for insurance benefits under this law. These means the expenses associate with freezing your sperm are covered, except for long-term storage which you are responsible for on your own. The same applies for female to male transition.
Limitations on Coverage:
I’m 42 and my doctor is recommending that I pursue donor egg treatment, but my insurance company is refusing to pay because I’m over the age of 40. My insurance company says menopause is a natural female condition and thus I have no insurance benefits. Is my insurance company correct?
The law was written with the intention that donor egg treatment be covered at all ages, when medically appropriate. Please reach out to me so we can set up some time to talk more about this issue and what you can do.
I’m purchasing frozen eggs from a donor egg bank. My IVF clinic tells me that insurance won’t pay for any of my treatment because donor eggs are never covered. Is that right?
The law does not permit an arbitrary exclusion for frozen donor eggs. The problem you run into is that the cost for a batch of donor eggs lumps together both medical expenses related to the egg retrieval and non-medical expenses. The insurance company is only obligated to pay for medical expenses, so it’s unclear at this time how this will be sorted out. The medical expenses that occur post-thawing should be covered under the law. This would include the fertilization of the eggs and culturing the embryos in the laboratory.
I’m a cancer survivor. The treatment for my cancer was a partial hysterectomy–the removal of my cervix and uterus. I’m ready to pursue having a baby through surrogacy. Since I still have my ovaries, I’d like to proceed with egg retrieval. My insurance company is refusing to pay, claiming that I was “voluntarily sterilized.” I don’t consider my hysterectomy voluntary by any means–my options were to remove my uterus or die of cancer. Can my insurance company really get away with this?
Your type of situation is generally referred to as elective because, it was non-urgent. An urgent hysterectomy would be the kind performed on a woman who is hemorrhaging post-birth and needs immediate life-saving treatment. But your hysterectomy doesn’t feel elective, does it? The law was written with the intention that medically-necessary hysterectomies, such as yours, not be treated as “voluntary sterilization.” If your insurance company is giving you a hard time about this, then let’s talk–consults are always free.
My husband had a vasectomy during his first marriage. I always knew I wanted kids, so he had the vasectomy reversed after we got married. The reversal was successful but I still couldn’t get pregnant. I went for a fertility workup, and it turns out I have premature ovarian insufficiency at age 34. My doctor strongly recommended I pursue IVF as my best option to have a genetic baby of my own. But my insurance company refuses to approve the IVF cycle because my husband had a voluntary sterilization (before I even met him!!). Can the insurance company do this?
Nothing in the fertility insurance law authorizes an insurance company to limit an individual’s treatment coverage based on the fact that a spouse had a voluntary sterilization procedure. Please contact me so we can discuss this further.
My wife and I need to pursue IVF (with ICSI) because I have a very low sperm county. Our reproductive endocrinologist assures us that we have a very good chance at having a baby through IVF using ICSI. Our insurance company refuses to authorize IVF and ICSI because there is no evidence that my wife is infertile. The insurance company is requiring that we “prove” my wife’s infertility through 12 cycles of IUI using donor sperm before we can be approved for IVF with my sperm. I’m not necessarily opposed to using donor sperm, but I feel like that’s a decision for my wife and I to make for ourselves. I don’t think it’s the insurance company’s place to require us to use donor sperm. Is the insurance company out-of-line here?
The law specifically recognizes the fact that infertility can be diagnosed in a man when he is unable to cause pregnancy in his partner. The law does not require that the man’s female partner also be infertile in order for the man to receive medical care appropriate for his male factor infertility. Get in touch to schedule some time to talk so we can go over your options moving forward.
My boyfriend and I have been in a committed relationship for ten years. We have been unsuccessful at conceiving a baby together on our own. Our diagnosis is “unexplained” and my doctor recommends we try three cycles of medicated IUI before thinking about IVF. Medicated IUIs are not cheap, so we’d like to have insurance coverage. The problem is that insurance refuses to pay because my boyfriend and I are not married. Can they really exclude us for not being legally married?
The law does not allow different benefits to be provided to unmarried couples and married couples.
Insurance Denials & Appeals
What are my next steps if my insurance company denied coverage for my fertility care?
If your insurance claim is denied, you have the option of filing an appeal. You can also file an appeal if your insurance company refused to pre-authorize your treatment (this is something that often comes up with IUI and IVF cycles). The appeals process involves, at a minimum, two levels of appeal. If you are seeking coverage for fertility preservation prior to chemotherapy (or have other urgent circumstances), an expedited appeal process is available. Other options may also be available to you, depending on the nature of your issue.
I can assist you with navigating the appeal process, for a low fixed fee. I can also assist you by providing more comprehensive representation during the full appeal process, if you prefer.
If you want to set up a free consult to talk about insurance (or anything else fertility law related), get in touch.