(FILES) This file photo taken on August 5, 2010 shows a pregnant woman walking outside the State Department in Washington, DC. / AFP PHOTO / Timothy SLOANTIMOTHY SLOAN/AFP/Getty Images
ALBANY — Starting Jan. 1, New Yorkers looking to build families will have greater access to in vitro fertilization and fertility preservation services thanks to a hard-fought law that significantly expands insurance coverage for the services.
The new law, enacted as part of the 2020 state budget, requires private, large-group health plans serving more than 100 employees to cover up to three cycles of in vitro fertilization (IVF) for infertile members. Individual, small- and large-group health plans, meanwhile, will be required to cover fertility preservation services, such as egg or sperm freezing, for members whose medical treatment will render them infertile, such as cancer patients who need radiation.
The new requirements, which do not apply to public or self-funded health plans, come as more and more young adults delay parenthood in favor of pursuing higher education or advancing their careers. They were enacted, in part, due to the large number of New Yorkers who avoid such services due to the cost.
“This new law will help break down economic barriers that have prevented too many individuals and families from having a child of their own and give New Yorkers more control over their reproductive health and family planning decisions,” Gov. Andrew Cuomo said Tuesday.
Cuomo issued a reminder about the new law Tuesday, and shared guidance from the state Department of Financial Services that answers frequently asked questions from patients who are curious about who’s eligible and what’s covered.
Here’s what you should know:
Who’s eligible for IVF? Anyone who receives insurance through the large-group market (employees at businesses with 100 or more employees) and who is diagnosed with infertility, which the law defines as an incapacity to conceive following 12 months of regular, unprotected sex or donor insemination. Women age 35 and older are considered infertile after only six months.
What IVF services are covered? The law requires coverage for three cycles of IVF over a member’s lifetime, including any medications prescribed in connection with the service, even if the health plan does not otherwise include a prescription drug benefit. Egg and/or embryo storage is also covered if it’s considered medically necessary while the three IVF cycles are underway.
What counts toward the three cycles? A frozen embryo transfer cycle counts toward the three-cycle limit. A cycle that was begun but not finished also counts. A cycle paid for by the member out of pocket, or covered by another health insurance plan, does not count. Cycles completed prior to 2020 also do not count.
What about fertility preservation services? Who’s eligible? Individuals whose medical treatment will directly or indirectly impair their fertility (such as cancer patients undergoing radiation or individuals seeking gender-affirming surgery) are eligible so long as they are also part of an individual, small- or large-group insurance plan that provides hospital, surgical, medical, major medical or comprehensive care.
What services are covered? Standard fertility preservation services — including the collecting, preserving and storage of eggs or sperm — must be covered, including any prescription drugs used in the process.
For how long? It’s unclear how long insurers must cover the storage of eggs or sperm. The law does not include a specific time limit for storage, and gives health plans the option to review this service for medical necessity.
Will either service — IVF or fertility preservation — cost me anything? Probably. Health plans can impose deductibles, copayments and coinsurance on the services, but those charges must be consistent with other covered services.
What about red tape? Insurers may require prior authorization for these services, meaning the provider must check with the insurer first to make sure the service is covered before providing it. Insurers can also review the services to determine if they are medically necessary. You should also check your plan’s network coverage rules. If your plan only provides for in-network benefits, service coverage could be limited to in-network providers — unless the insurer doesn’t have an in-network provider with appropriate training and expertise. If the plan covers out-of-network services, coverage for out-of-network IVF or fertility preservation services must also be provided.
What can’t my insurer do? Unlike IVF services, insurers cannot impose a lifetime limitation on fertility preservation services. For both IVF and fertility preservation services, your insurer cannot impose an annual dollar limit or age restriction. They also cannot discriminate based on a member’s expected life span, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, or personal characteristics such as age, sex, sexual orientation, marital status or gender identity.
For more information, such as what’s covered if you switch plans, visit dfs.ny.gov.
Bethany Bump writes about all things health, including state and local health policy, addiction and mental health for the Times Union. She has previously covered education, business and local governments, and won awards for her coverage of health care and addiction issues. Bump joined the Times Union in 2015, after a four-year stretch at The Daily Gazette in Schenectady, N.Y. She graduated from Syracuse University’s S.I. Newhouse School of Public Communications in 2011, with a bachelor’s degree in journalism and political science. Contact her at 518-454-5387, [email protected] or on Twitter @bethanybump.