What You Must Know About California"s Infertility Insurance Mandates
California is one of 15 states that currently has some form of infertility insurance mandate, and knowing what it does and does not offer state residents is very important if you find yourself dealing with infertility.
According to California's Health and Safety Code 1374.
55 "(a) On and after January 1, 1990, every health care service plan contract which is issued, amended, or renewed that covers hospital, medical, or surgical expenses on a group basis, where the plan is not a health maintenance organization as defined in Section 1373.
10, shall offer coverage for the treatment of infertility, except in vitro fertilization, under those terms and conditions as may be agreed upon between the group subscriber and the plan.
Every plan shall communicate the availability of that coverage to all group contract holders and to all prospective group contract holders with whom they are negotiating.
" As long as you do not have an HMO plan and work for a company that employs fewer than 20 individuals, do not work for a religious organization, and your health care plan is not "self-insured", infertility diagnosis and treatment (except for IVF) should be offered in a health care plan to your employer.
Even though IVF, or in vitro fertilization is not included in the coverage mandate, the diagnosis, diagnostic testing, medication, surgery, and GIFT or gamete intrafallopian transfer is included and must be covered in any plan that includes infertility coverage.
Now, this does not mean that you cannot have IVF, it just means that the insurance policy is not required to cover the cost of the actual fertilization of the egg "in vitro".
If your doctor or fertility clinic will break down the cost for services associated with IVF, you would have to pay for the "fertilization" outside of the womb yourself.
You may also be able to provide a case for needing to have IVF done versus GIFT if both of your fallopian tubes are completely blocked and cannot be cleared with any medical or surgical treatment.
Obviously, under these circumstances IVF would become "medically necessary" and GIFT would not be a viable treatment option for you.
This does not mean that your insurance company will or even has to cover IVF, but that you should examine all options and discuss all possibilities for treatment with your insurance company.
If your insurance company is willing to cover all costs except for the fertilization of the egg outside of the womb, your out of pocket expense for having IVF to treat your infertility will be greatly reduced to about $2000 plus any deductible and normal out of pocket costs.
Bottom line is that though your employer is not required to purchase the insurance that offers infertility coverage, the insurance companies are required to offer it as an option.
If your plan currently does not include any infertility coverage, talk with the human resources manager or benefits manager to see if it is possible to have your company offer more than one plan to all employees.
According to California's Health and Safety Code 1374.
55 "(a) On and after January 1, 1990, every health care service plan contract which is issued, amended, or renewed that covers hospital, medical, or surgical expenses on a group basis, where the plan is not a health maintenance organization as defined in Section 1373.
10, shall offer coverage for the treatment of infertility, except in vitro fertilization, under those terms and conditions as may be agreed upon between the group subscriber and the plan.
Every plan shall communicate the availability of that coverage to all group contract holders and to all prospective group contract holders with whom they are negotiating.
" As long as you do not have an HMO plan and work for a company that employs fewer than 20 individuals, do not work for a religious organization, and your health care plan is not "self-insured", infertility diagnosis and treatment (except for IVF) should be offered in a health care plan to your employer.
Even though IVF, or in vitro fertilization is not included in the coverage mandate, the diagnosis, diagnostic testing, medication, surgery, and GIFT or gamete intrafallopian transfer is included and must be covered in any plan that includes infertility coverage.
Now, this does not mean that you cannot have IVF, it just means that the insurance policy is not required to cover the cost of the actual fertilization of the egg "in vitro".
If your doctor or fertility clinic will break down the cost for services associated with IVF, you would have to pay for the "fertilization" outside of the womb yourself.
You may also be able to provide a case for needing to have IVF done versus GIFT if both of your fallopian tubes are completely blocked and cannot be cleared with any medical or surgical treatment.
Obviously, under these circumstances IVF would become "medically necessary" and GIFT would not be a viable treatment option for you.
This does not mean that your insurance company will or even has to cover IVF, but that you should examine all options and discuss all possibilities for treatment with your insurance company.
If your insurance company is willing to cover all costs except for the fertilization of the egg outside of the womb, your out of pocket expense for having IVF to treat your infertility will be greatly reduced to about $2000 plus any deductible and normal out of pocket costs.
Bottom line is that though your employer is not required to purchase the insurance that offers infertility coverage, the insurance companies are required to offer it as an option.
If your plan currently does not include any infertility coverage, talk with the human resources manager or benefits manager to see if it is possible to have your company offer more than one plan to all employees.
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