California

2024 Update

Additional Coverage

Requires large group markets (more than 100 employees) and CalPERS (state employee) plans to provide coverage for the diagnosis and treatment of infertility and fertility services, including IVF. For the large group fully-insured plans (more than 100 employees) issued, amended, or renewed on or after July 1, 2025 and for Cal PERS (state employees) plans on or after July 1, 2027, coverage is required for the diagnosis and treatment of infertility and fertility services, including a maximum of three completed oocyte retrievals with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine (ASRM), using single embryo transfer when recommended and medically appropriate.

Exemptions

Does not require religious organizations to offer coverage.

Fertility preservation coverage does not apply to Medi-Cal managed care health care service plan contracts.

Employers who self-insure are exempt from the requirements of the law.

Statute

Section 1. Section 1374.55 of the Health and Safety Code is repealed.
Section 2. Section 1374.55 is added to the Health and Safety Code
Section 3. Section 10119.6 of the Insurance Code is repealed.
Section. 4. Section 10119.6 is added to the Insurance Code

Coverage Mandate ¹:

Yes

Scope of Mandate ²:

Effective 1/1/1990.

California law requires insurers and health care service plans to offer coverage of infertility treatment, except IVF.* Cal. Health & Safety Code § 1374.55; Cal Ins. Code § 10119.6. With respect to HMOs, this only applies to group contract holders with at least 20 employees to whom the plan is offered.

“Infertility” means either (1) the presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or (2) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception. Cal. Health & Safety Code § 1374.55(b); Cal Ins. Code § 10119.6(b).

“Treatment for infertility” means procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Id.

“In vitro fertilization” means the laboratory medical procedures involving the actual in vitro fertilization process. Id.

Coverage Cap ³:

Requirements or Limitations on Coverage ⁴:

No infertility treatment coverage is required. Insurers are only required to offer the following services to employers who decide if they will provide the following benefits to their employees: diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT).

When a covered treatment may cause iatrogenic infertility to an enrollee, standard fertility preservation services are a basic health care service; these provisions are declaratory of existing law that requires every health care service plan contract to provide enrollees with basic health care services.

Exemptions ⁵:

Only requires insurers to offer infertility treatment coverage.

Does not include IVF.*

Does not require religious organizations to offer coverage.

Fertility preservation coverage does not apply to Medi-Cal managed care health care service plan contracts.

Employers who self-insure are exempt from the requirements of the law.

Fertility Preservation:

Yes

Notes

In the 2021-22 session, CA introduced AB-797, which would amend the mandate to require commercial insurers to cover infertility treatment. Under this bill, the language of infertility is revised to include LGBTQ+ and single people.

¹ Does the state have a coverage mandate, Y/N. Include effective date of the mandate. Specify if the mandate is to “offer” services or to “cover” them.

²Which insurers are required to comply with the mandate. If not applicable, put N/A.

³Is there a cap (annual/lifetime)?

⁴Does the law impose age restrictions on eligibility for coverage? Does it limit the number of IVF cycles covered (or require at least a certain number of services be covered)? Does it mandate a waiting period? Other limitations? How is “infertility” defined? Is it inclusive (e.g.: does it apply only to married or -opposite sex couples, or is it inclusive?)

⁵What, if any, exemptions apply to coverage under the mandate? For example: an exemption for small businesses or religious organizations.

Resources For You

The American Society for Reproductive Medicine (ASRM) is committed to providing patients with the highest quality information about reproductive care.