Know your rights: The Massachusetts Infertility Mandate

massachusetts

The Massachusetts infertility mandate, enacted in 1987, is hailed as one of the most comprehensive in the country by requiring infertility be treated like any other medical condition and not mandating a cap on coverage (either in number of cycles or a lifetime dollar amount). Individual insurance policies do have the right to limit the number of cycles covered based on clinical guidelines or patient medical history. In 2005, the state expanded coverage to state funded health programs.

Further information is clarified in the Massachusetts General Laws, Chapter 175, Section 47H. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

The Massachusetts mandate defines infertility as “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. 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.”

Eligibility requirements

Patient requirements: Patient must be a policy holder or the spouse (and covered dependent) of the policy holder and be diagnosed with infertility (as defined above). Additionally, IVF can only be covered if patient is unsuccessful achieving pregnancy with less expensive treatment options covered by the plan.

Clinic Requirements: IVF procedure must be performed at a fertility clinic or medical facility that conforms to standards and guidelines set by the American Society for Reproductive Medicine (ASRM) or the American College of Obstetricians and Gynecologists. Procedures must be recognized by a scientific body such as the American Society of Reproductive Medicine, American College of Obstetrics and Gynecology or the Society of Assisted Reproductive Technology. Experimental procedures will not be covered.

How the law treats male infertility

The law does not specifically define coverage requirements for male related services and treatments. However, Chapter 46, section 4B explicitly creates paternal rights for married men whose wives conceive via artificial insemination or IVF with donor sperm.

Services that are covered

All approved fertility treatments are covered. Insurers are required to treat infertility like any other condition. The following treatments are specifically listed in the mandate:

  • Artificial insemination or IUI
  • IVF
  • GIFT
  • Sperm, egg and/or inseminated egg procurement and processing
  • Banking of sperm or inseminated eggs, to the extent such costs are not covered by the donor’s insurer,
  • ICSI
  • ZIFT
  • Assisted hatching
  • Cryopreservation of eggs.

Additional protections: The law goes out of the way to protect infertility patients by requiring co-pays and deductibles for fertility related expenses to be the same as all other conditions, prohibiting pre-existing condition clauses and placing caps on the amount of cycles that can be covered.

Limitations on coverage

The following procedures identified in the mandate as exempt:

  • Sterilization procedures or reversals (vasectomy or tubal ligation)
  • Surrogacy
  • Experimental fertility treatments
  • Egg freezing

Exemptions

The following organizations are exempt from providing coverage:

  • Self-ensured organizations
  • Companies that are not headquartered in MA

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 possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

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). You may also be able to connect with other people in your area via our local forum boards.

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.