Know your rights: The California Infertility Mandate

california

The California Infertility Mandate, enacted in 1989, requires health plan to offer at least one plan that includes infertility treatment…except IVF.

Overall, the California mandate is pretty weak. It only requires insurance companies to offer at least one plan that has coverage for infertility care, but it doesn’t require employers to offer these plans nor does it require any plans to include coverage for IVF. The law was amended in 2013 to include clauses that made it illegal to withhold fertility services to any person who is covered, regardless of gender, gender identity, genetic information, sexual orientation or marital status (among other things).

Further information is clarified in section 1374.55 of the California Health and Safety Code which became effective in 1990. 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:

  • Presence of a medical condition that causes infertility, as diagnosed by a medical professional
  • Inability to conceive or carry a child to term after a year or more of unprotected sexual intercourse

Eligibility requirements

The law has no additional eligibility requirements beyond a diagnosis of infertility (as defined above) and purchasing a plan that provides infertility coverage.

The law prevents employer or health insurance companies from discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation.

How the law treats male infertility

No specific mention of male infertility.

Services that are covered

  • Diagnostic testing
  • Medications
  • Surgeries
  • Gamete intrafallopian transfer (GIFT)

Limitations on coverage

  • IVF, defined as a procedure involving an in vitro fertilization process, is excluded from the mandate
  • Coverage is not required, only the ability to purchase coverage.

Exemptions

  • No employer is required to offer insurance to employees, the law only requires that insurance companies must have at least one plan that includes fertility coverage.
  • Religious employers are specifically called out as not being required to offer coverage for any forms of treatment that are inconsistent with religious or ethical principles.
  • Employers who are self-insured are also exempt.

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 is covered and what isn’t. If your plan does not cover fertility services, you may want to look at the other options more closely during open enrollment to see if your organization offers any plans that include coverage.

Learn what things cost: Knowing costs associated with different tests and fertility treatments allows you to plan. You can get a general idea of cost range through internet research, but you should call your physician to get specifics as prices vary by practice. Some practices may hesitate to provide costs up front not knowing what you will need. It may help to ask for costs of specific tests or treatments or to schedule an appointment with the practice financial coordinator if they have one.

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 can help you qualify for additional resources.

Talk to a financial counselor: Many fertility clinics have a financial counselor on-staff who is available to work with patients to develop a plan that enables them to afford fertility care. The financial counselor may be able to help you figure out what costs you are likely to incur, determine if any of the expenses are able to be billed, negotiate a payment plan, get discounts or apply for financial assistance.

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 others in your area in our local forums.

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.