The New York infertility mandate requires treatment for conditions that result in infertility, such as endometriosis and hypogonadism. It does not require insurance companies to cover costs associated with assisted reproduction but pushes for the treatment of underlying medical conditions that result in infertility. In addition to the mandate, the state has created a public funding source to assist couples with costs associated with assisted reproduction, in the case that insurance benefits do not cover treatment. In 2015, there was a new bill to require coverage for IVF, but as of the beginning of 2018, the bill was still held up in committee.
Further information is clarified in New York Consolidated Laws, Insurance, Sections 3221 and 4303. A summary of eligibility requirements, exemptions and services covered is outlined below.
How the mandate defines infertility
The New York mandate states that infertility shall be determined in accordance to the guidelines established by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine.
Patient requirements: Patient must be between the ages of 21 and 44 and have been covered under the policy for at least 12 months.
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.
How the law treats male infertility
The New York Mandate looks at male and female infertility equally. It specifically calls out male focused tests and procedures as eligible for coverage including semen analysis, blood tests and testicular biopsy.
Services that are covered
The following treatments are specifically listed in the law:
- Diagnostic tests and procedures
- Endometrial biopsy
- Post coital tests
- Testis biopsy
- Semen analysis
- Blood tests and ultrasound
- Medications approved by FDA for treatment of infertility
Additional services: In 2002, New York State passed legislation called the Infertility Demonstration Program, which provide grants to select IVF clinics. The grants help subsidize payments for most services associated with IVF, including patient assessment (1 allowed per patient for the life of the grant) and the IVF cycle (maximum of 2 complete cycles for the life of the grant). The amount of treatment funding provided to the eligible individual/couple is based on the individual/couple’s combined household income; coverage can range from 2.5% up to 97.5% of IVF treatment costs.
Limitations on coverage
The following procedures are explicitly excluded from the mandate:
- In vitro Fertilization (IVF)
- Vasectomy Reversal
The following are exempt from providing coverage:
- Individually purchased plans
- Self-insured plans
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.
- Fertility Authority: New York Infertility Mandate
- Resolve: Insurance coverage by State
- National Conference of State Legislatures: State Laws related to insurance coverage for infertility treatment
- New York Infertility Demonstration Program
- New York Consolidated Laws, Insurance: Sections 3221 and 4303
- New York: Senate Bill S5569