Know your rights: The Connecticut Infertility Mandate

connecticut

The Connecticut infertility mandate, enacted in 1989, requires health insurance organizations to provide coverage for medically necessary expenses in the diagnosis and treatment of infertility, including IVF procedures. It was amended in 2005, to allow exemptions for religious organization from coverage that is contrary to religious beliefs and again in 2016 to remove age limits on benefits and to explicitly include male infertility.

Further information is clarified in the Connecticut Bulletin HC-104 which became effective January 1, 2016. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

The legal definition of infertility in this mandate is “the condition of an otherwise healthy individual who has been unable to conceive or sustain a successful pregnancy during a one-year period.”

Additional Eligibility requirements

Insurance requirements: Patients must be policy holders for 12 months and must disclose prior fertility treatments (covered by a different plan) to the insurance provider.

Medical requirements: Patient must be healthy, and treatment must be medically necessary. Doctors or insurance providers may use reasonable medical management to determine if the patient is healthy or if the treatment is necessary. Note that as of 2016, age has been removed as a reason to exclude treatment.

Medical facilities: Fertility treatments must be performed at fertility clinics or facilities that conform to the guidelines developed by the American Society for Reproductive Medicine (ASRM) or the Society of Reproductive Endocrinology and Infertility.

How the law treats male infertility

The Connecticut mandate is one of the few states that explicitly covers male infertility through a 2016 amendment that states “Male infertility treatment is covered under this mandate.”

Services that are covered

Other services may be covered at the discretion of the insurance company, but the following services are explicitly called out by the mandate.

  • Ovulation induction
  • Intrauterine Insemination (IUI)
  • In Vitro Fertilization (IVF)
  • Uterine embryo lavage
  • Embryo Transfer
  • Gamete Intrafallopian Transfer (GIFT)
  • Zygote Intrafallopian Transfer (ZIFT)
  • Low tubal ovum transfer.

Limitations on coverage

  • Lifetime maximum 4 cycles of ovulation induction
  • Lifetime maximum of 3 IUIs
  • Lifetime maximum of 2 cycles of IVF, GIFT, ZIFT, low tubal ovum transfer with no more than 2 embryos per cycle

Exemptions

The following organizations are exempt from providing coverage:

  • Religious organizations
  • Self-insured organizations

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as you can will not only improve your overall fertility but since the mandate requires patients to be healthy prior to treatment chronic health conditions, high BMI, tobacco use and other health issues may prevent your ability to access fertility care.

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups).

References:


Sara SDx

Sara SDx

Editor of Don't Cook your Balls, Co-Founder of TrakFertility.com, Health Coach and Men's Health Advocate. Passionate about sperm, men's health and helping people build their families.
Sara SDx

Author: Sara SDx

Editor of Don't Cook your Balls, Co-Founder of TrakFertility.com, Health Coach and Men's Health Advocate. Passionate about sperm, men's health and helping people build their families.