Mandated Insurance Coverage in New England

New England Infertility Mandates Only three of the six New England region states mandate insurance coverage of infertility treatment and/or diagnosis: Connecticut, Massachusetts and Rhode Island. For questions about your individual state’s mandated coverage, consider joining our Insurance Advocate Call-In Hours.

Overview of Coverage by State

Connecticut Infertility Mandate

Summary

Public Act No. 05-196, enacted in 1989 and becoming law in 2005, mandates that insurance companies in Connecticut must cover infertility diagnosis and treatment for individuals under the age of 40.

Legal Definition of Infertility

The Act defines infertility as “the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.”

Limits

This mandate does limit lifetime maximum coverage for ovulation induction (4 cycles), intrauterine insemination (3 cycles), and IVF, GIFT, ZIFT or low tubal ovum transfer (2 cycles). Treatment must be performed at fertility clinics that conform to the guidelines developed by the American Society of Reproductive Medicine (ASRM) and the Society of Reproductive Endocrinology and Infertility (SREI).

Exemptions

Religious employers and employers who self-insured are exempt from the Connecticut insurance mandate requirements.

For more information about the Connecticut Insurance Mandate, please consult Public Act No. 05-196 and BULLETIN HC-64.

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Massachusetts Infertility Mandate

Summary

Mass Gen Laws Ann. Ch. 175 and Ch. 176 and 211 CMR 37.00, enacted in 1987 and amended in 2010, mandates that insurance companies in Massachusetts must cover infertility diagnosis and treatment for individuals, which certain limits and exemptions, but covering the following procedures:

Artificial Insemination (AI); In Vitro Fertilization and Embryo Placement (IVF-EP); Gamete Intra fallopian Transfer (GIFT); Sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or inseminated eggs, to the extent such costs are not covered by the donor’s insurer, if any; Intracytoplasmic Sperm Injection (ICSI) for the treatment of male factor infertility; Zygote Intrafallopian Transfer (ZIFT).

Legal Definition of Infertility

“Infertility” shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35.

Additional Definitions

For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable.

Limits

No insurer shall be required to provide benefits for any experimental infertility procedure, until the procedure becomes recognized as non-experimental and is so recognized by the Commissioner; surrogacy; reversal of Voluntary Sterilization; cryopreservation of eggs. These procedures are at the optional coverage discretion of the individual insurance provider.

Exemptions

Employers who self-insured are exempt from the Massachusetts insurance mandate requirements.

For more information about the Massachusetts Insurance Mandate, please consult , Mass Gen Laws Ann. Ch. 175, Section 47H, ch. 176A, Section 8K, ch. 176B, Section 4J, ch. 176G, Section 4, and 211 CMR 37.00.

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Rhode Island Infertility Mandate

Summary

RI Gen. Laws sections 27-18-30, 27-19-23, 27-20-20, and 27-41-33, enacted in 1989 and amended in 2007, mandates that insurance companies in Rhode Island must provide coverage for medically necessary expenses of diagnosis and treatment of infertility for women between the ages of 25 and 42 years.

Legal Definition of Infertility

“Infertility” means the condition of an otherwise healthy married individual who is unable to conceive or sustain a pregnancy during a period of one year.

Limits

The health insurance contract may limit coverage to a lifetime cap of $100,000.

Exemptions

Employers who self-insured are exempt from the Rhode Island insurance mandate requirements.

For more information about the Rhode Island Insurance Mandate, please consult RI Gen. Laws sections 27-18-30, 27-19-23, 27-20-20 and 27-41-33.

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