New York

Coverage Mandate ¹:

Yes

Effective 1/1/2020.

Large group insurance policies and large contracts issued by hospital service corporations and health service corporations that provide medical, major medical or similar comprehensive-type coverage must provide coverage for 3 cycles of in-vitro fertilization used in the treatment of infertility. N.Y. Ins. Law §§ 3221(k)(6)(C)(vii), 4303(s)(3)(G).

A “cycle” of in-vitro fertilization is defined as all treatment that starts when preparatory medications are administered for ovarian stimulation for oocyte retrieval with the intent of undergoing in-vitro fertilization using a fresh embryo transfer or when medications are administered for endometrial preparation with the intent of undergoing in-vitro fertilization using a frozen embryo transfer. Id. §§ 3221(k)(6)(C)(vii), 4303(s)(3)(G).

Individual and small group accident and health insurance policies that provide hospital, surgical, or medical expense coverage (not grandfathered health plans) and student accident and health insurance policies must provide coverage for infertility treatment. N.Y. Comp. Codes R. & Regs. tit. 11, § 52.71

The term “infertility treatment” is not defined.

Scope of Mandate ²:

Coverage Cap ³:

Requirements or Limitations on Coverage ⁴:

To meet the definition of infertility, the individual must be unable to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or therapeutic donor insemination, or after 6 months of regular, unprotected sexual intercourse or therapeutic donor insemination for a female 35 years of age or older. Earlier evaluation and treatment may be warranted based on an individual's medical history or physical findings. N.Y. Ins. Law §§ 3221(k)(6)(C)(v)(I), 4303(s)(3)(E)(i).

Individual, group or blanket health insurance policies and contracts issued by hospital service corporations and health service corporations that provide coverage for hospital care or surgical and medical care must not exclude coverage for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility. Id. §§ 3216(i)(13)(A)-(B), 3221(k)(6)(A)-(B), 4303(s)(1)-(2).

Exemptions ⁵:

Fertility Preservation:

Yes

Effective 1/1/2020.

Group policies, individual policies that provide medical, major medical, or similar comprehensive-type coverage, and hospital service corporations and health service corporations that provide coverage for hospital care or surgical and medical care must provide coverage for standard fertility preservation services when a medical treatment may directly or indirectly cause iatrogenic infertility. N.Y. Ins. Law §§ 3216(i)(13)(C), 3221(k)(6)(C)(vi), 4303(s)(3)(F).

Coverage may be subject to annual deductibles and coinsurance, including copayments. Id. §§ 3216(i)(13)(C), 3221(k)(6)(C)(vi), 4303(s)(3)(F).

The term “standard fertility preservation services” is not defined.

“Iatrogenic infertility” means an impairment of fertility by surgery, radiation, chemotherapy or other medical treatment affecting reproductive organs or processes. Id. §§ 3216(i)(13)(C)(i), 3221(k)(6)(C)(v)(II), 4303(s)(3)(E)(ii).

Notes

N.Y. Pub. Health Law § 2807(1)(jj) creates a grant program from the tobacco control and insurance initiatives pool to improve access to infertility services, treatments and procedures.

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.

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