The Difference Between State Mandates to Cover and to Offer Infertility Insurance Coverage

Out of the 15 states that have mandated coverage of infertility in health insurance policies, only California and Texas have mandates to offer coverage in health care policies. What this means to a couple dealing with infertility is that their employer has the option to purchase health insurance that offers some coverage for infertility testing, diagnosis and treatment, but they are not required to buy such insurance.

There are many factors that go into the choice of which insurance policy or policies to purchase and offer to employees, price being one of them. If you live in California or Texas and your employer’s choice of insurance coverage does not include any infertility coverage, you should talk to your human resources manager or the manager of benefits and find out if it would be possible to have the company offer additional health insurance policy options with at least one of them offering infertility coverage.

The company may not want to offer such insurance if their costs will be going up, especially if they believe that only one or two employees want such coverage. So go a little grass roots and find out if your co-workers would be willing to pay more for such coverage, and ask them all to ask for it as an option in future insurance offerings. You may be surprised at how many co-workers would like such coverage and your company may surprise you and offer additional choices in insurance coverage in the future.

That leaves us with 13 states, listed just below along with some information, that have mandates to cover. Depending on the wording of the law for each state, health insurance policies and/or HMOs that offer anything from basic coverage to maternity coverage, must also cover some infertility testing, diagnosis and treatments. Basically, a mandate to cover is just that, they must cover “something” where infertility is concerned and many of the state laws state specifically what must be covered too.

  • Arkansas – HMOs and self-insurers exempt; all individual and group policies that cover maternity must cover
  • Connecticut – Self-insurers and religious organizations exempt; all individual and group policies must cover
  • Hawaii – Self-insurers exempt; all individual and group policies must cover
  • Illinois – Self-insurers, religious employers, and companies with fewer than 25 employees exempt; all group and HMOs that cover pregnancy must cover
  • Louisiana – Self-insurers exempt; cannot exclude coverage just because condition results in infertility
  • Maryland – Self-insurers, religious employers, and companies with fewer than 50 employees exempt; all individual and group policies that cover pregnancy must cover
  • Massachusetts – Self-insurers exempt; all insurers that cover pregnancy must cover
  • Montana – Self-insurers exempt; HMOs required to cover as basic health care
  • New Jersey – Self-insurers, religious employers, and companies with fewer than 50 employees exempt; group insurers and HMOs that cover pregnancy must cover
  • New York – Self-insurers exempt; group policies must cover testing and diagnosis
  • Ohio – Self-insurers exempt; HMOs required to cover as basic health care
  • Rhode Island – Self-insurers exempt; individual and group policies and HMOs that cover pregnancy must cover
  • West Virginia – Self-insurers exempt; HMOs required to cover as basic health care

A state mandate to cover means that unless a business’s group, and in some cases individual, health care insurance is exempt, some form of infertility coverage must be included in the policy. On the flip side of the issue is the state mandate to offer, which only means that the insurance company has to offer for sale a policy that includes infertility coverage, but the business is not required to purchase that coverage. Knowing not only what your insurance policy states is covered, but also what your state’s mandate is, can help you when navigating the world of infertility and insurance coverage.