Know your rights: The Maryland Infertility Mandate

maryland

The Maryland infertility mandate, enacted in 1985, requires group insurance carriers that offer pregnancy benefits to also cover diagnosis and treatment for infertility including in vitro fertilization (IVF) procedures. This law is more generous than most by allowing 3 IVF cycles per live birth and a lifetime maximum of $100,000 worth of coverage. Recently, Maryland updated the mandate to enable use of donated sperm or eggs and to cover same sex couples who have difficulty conceiving.

Further information is clarified in the Maryland Insurance Article Section 15-810 last updated in July 2016. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

To qualify for treatment, you must have one of the following conditions:

  • Unexplained infertility for at least 2 years
  • Endometriosis
  • DES (In Utero to Diethylstilbestrol)
  • Blockage or removal of fallopian tubes (not including voluntary sterilization)
  • Male Infertilty
  • 6 failed artificial inseminations for same sex couples

Eligibility requirements

Patient requirements: Patient must be a policy holder or the spouse (and covered dependent) of the policy holder, be diagnosed with infertility (as defined above)and must be 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.

How the law treats male infertility

Maryland may be one of the most friendly mandates towards male infertility. It calls out “male factors” and “oligospermia” as causes of infertility. It also covers the use of donor sperm in an IVF cycle if “the patient’s spouse is unable to produce and deliver functional sperm, and
the inability to produce and deliver functional sperm does not result from a vasectomy or another method of voluntary sterilization.” It does not however mandate infertility services that are for men such as sperm retrieval, varicocele correction or use of fertility drugs to improve sperm production.

Services that are covered

While other fertility treatments may be covered at the discretion of the insurer, In Vitro Fertilization is the only treatment specifically called out in the mandate. Donor sperm may be used for sex sex couples and hetrosexual couples for whom the male partner is unable to produce functional sperm.

Limitations on coverage

  • Does not cover reversal of sterilization procedures (vasectomy or tubes tied)
  • Does not cover IVF if either partner has undergone sterilization procedure
  • 3 IVF cycles per live birth
  • Lifetime benefit not to exceed $100,000

Exemptions

The following organizations are exempt from providing coverage:

  • Employers with fewer than 50 employees
  • Religious organizations
  • Self-ensured 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 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.