IVF Treatment Coverage Mandates: A State-by-State Breakdown
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Recent attempts by Congress to mandate nationwide IVF insurance coverage have come up short. Now, numerous state governments are passing their own requirements.
Insurance coverage of infertility treatments is one of the major benefit topics of the 2024 election. California is the most recent state to weigh in by passing Senate Bill 729, which requires fully insured, large group health plans to provide coverage for the diagnosis and treatment of infertility and fertility services.
Quick Overview: California Senate Bill 729
Large employers (100 or more employees) are required to cover the diagnosis and treatment of infertility, including in vitro fertilization (IVF). This includes a maximum of 3 completed oocyte retrievals and unlimited embryo transfers.
Additionally, the definition of infertility has been broadened, including LGBTQ+ individuals, who can also receive treatment. Religious employers, as defined by California law, are exempt. The law applies to all policies issued, amended, or renewed on or after July 1, 2025.
Twenty-two states and the District of Columbia currently have IVF coverage mandates on the books.
California's law does not impose this coverage mandate on small group plans or self-funded ERISA plans. However, the law prohibits health carriers and disability insurers, for both larger group and small group plans, from placing different conditions or coverage limitations on fertility medications and services compared to other treatments unrelated to infertility.
Currently, 22 states and the District of Columbia have laws on the books. While many are similar to California’s law, there are important differences. The chart below shows the current law in each of these states.
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States with IVF Insurance Coverage Laws
| State | Definition of Infertility | Coverage Requirements | Exemptions |
|---|---|---|---|
| Person and their spouse must be diagnosed with endometriosis; exposure to diethylstilbestrol (DES); blocked or surgically removed fallopian tubes (cannot be from voluntary sterilization); abnormal male factors contributing to infertility; OR a 2-year history of unexplained infertility. | • All policies that provide maternity benefits must cover IVF. • Lifetime maximum is $15,000. • Coverage is subject to the same deductibles and out-of-pocket maximums as other maternity benefits. • Person must be unable to become pregnant through less costly treatments covered by insurance. | Self-funded ERISA plans | |
| (a) Licensed physician diagnoses infertility. (b) Person’s inability to reproduce either as an individual or with their partner without medical intervention. (c) Failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. | • Large employers (100 or more employees) must cover a maximum of 3 oocyte retrievals. • Requires insurance policies to provide coverage for the diagnosis and treatment of infertility and fertility services. | 1. Religious employers 2. Self-funded ERISA plans | |
| A disease or condition characterized by: (a) failure to impregnate or conceive; (b) person’s inability to reproduce as an individual or with the person’s partner; (c) licensed physician’s findings based on patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing | • Large group plans (100 or more employees) must provide coverage for infertility and standard fertility preservation services, including 3 completed oocyte retrievals with unlimited embryo transfers. • No exclusions, limitations, or other restrictions on coverage of fertility medications that are different from any other prescription medications covered under the plan. • Coverage is subject to the same deductibles and out-of-pocket maximums as other maternity benefits. | 1. Self-funded ERISA plans 2. Religious employers 3. Individual and small group policies (unless HHS determines coverage for fertility services does not require defrayal by the state) | |
| Condition of an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period; or if treatment is medically necessary | • Individuals must have maintained coverage under a policy for at least 12 months. • Lifetime maximum coverage of 4 cycles of ovulation induction. • Lifetime maximum coverage of 3 cycles of intrauterine insemination. • Lifetime maximum coverage of 2 cycles of IVF, GIFT, ZIFT, or low tubal ovum transfer, with not more than 2 embryo implantations per cycle. • Coverage for IVF, GIFT, ZIFT, or low tubal ovum transfer is limited to individuals unable to conceive or sustain successful pregnancy through less expensive and medically viable treatments. | 1. Self-funded ERISA plans 2. Religious employers | |
| (a) Disease or condition that results in impaired function of the reproductive system whereby an individual is unable to procreate or carry a pregnancy to live birth. (b) For IVF – retrievals are completed before the individual is 45 years old and transfers are completed before the individual is 50 years old | • All individual, group, and blanket health insurance policies that provide for medical or hospital expenses shall include coverage for fertility care services, including IVF and standard fertility preservation services for individuals who must undergo medically necessary treatment that may cause iatrogenic infertility. • Benefits must be provided to the same extent as other pregnancy-related benefits. • Person has been unable to obtain successful pregnancy through reasonable effort with less costly infertility treatments covered by the policy, with certain exceptions. | 1. Self-insured ERISA plans 2. Religious employers 3. Employers with fewer than 50 employees | |
| 5-year history of infertility or infertility is associated with at least one of the following: endometriosis, DES exposure, blocked or surgically removed fallopian tubes, abnormal male factors contributing to infertility. | • Coverage is provided if the patient is unable to obtain successful pregnancy through other infertility treatments covered by the plan. • One cycle of IVF, performed at medical facilities that conform to ACOG and ASRM guidelines. • Coverage must be to the same extent as maternity-related benefits. | Self-funded ERISA plans | |
| Disease, condition, or status characterized by: (a) failure to establish pregnancy or carry pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility; (b) person's inability to reproduce either as a single individual or with a partner without medical intervention; or (c) licensed physician's findings based on a patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing. | • Plans that provide pregnancy-related coverage must provide infertility treatment including, but not limited to: diagnosis of infertility; IVF; uterine embryo lavage; embryo transfer; artificial insemination; GIFT; ZIFT; low tubal ovum transfer. • Coverage for IVF, GIFT, and ZIFT is provided if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, infertility treatments covered by insurance. • Lifetime maximum of six retrievals. • No exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications. • No deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, that are different from those imposed upon benefits for services not related to infertility. | 1. Religious employers 2. Employers with fewer than 25 employees 3. Self-funded ERISA plans | |
| Impairment of fertility caused by surgery, radiation, chemotherapy, or any other medical treatment affecting reproductive organs or processes. | All plans must provide coverage for oocyte and sperm preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility to an insured. | 1. Self-funded ERISA plans 2. Religious employers | |
| (a) Impairment of fertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment. (b) Oocyte and sperm preservation procedures that are consistent with established medical practices or professional guidelines published by the American Society of Clinical Oncology or the American Society for Reproductive Medicine. | • Plans must provide coverage for standard fertility preservation services for covered individuals who have been diagnosed with cancer and which necessary cancer treatment may directly or indirectly cause iatrogenic infertility. • Plans may exclude costs of storage of oocytes and sperm after three years. • Does not require coverage of fertility drugs, IVF other assisted reproductive techniques, reversal of tubal ligation, vasectomy, or other methods of sterilization. | 1. Self-funded ERISA plans 2. Religious employers | |
| Presence of a demonstrated condition recognized by a provider as a cause of loss or impairment of fertility or a couple's inability to achieve pregnancy after 12 months of unprotected intercourse when the couple has the necessary gametes for conception, including the loss of a pregnancy occurring within that 12-month period, or after a period of less than 12 months due to a person's age or other factors. | Plans must cover fertility diagnostic care, fertility treatment if the covered individual is a fertility patient, and fertility preservation services. | Self-funded ERISA plans | |
| For married individuals: (a) if person and their spouse are of opposite sexes, intercourse of at least 1 year’s duration failing to result in pregnancy. (b) if person and their spouse are of the same sex, three attempts of artificial insemination over the course of 1 year failing to result in pregnancy; or infertility if person or their spouse is associated with any of the following: endometriosis; DES exposure; blocked or surgically removed fallopian tubes; abnormal male factors contributing to the infertility. For unmarried persons: (a) Three attempts of artificial insemination over the course of 1 year failing to result in pregnancy; or infertility is associated with any of the following: endometriosis; DES exposure; blocked or surgically removed fallopian tubes; abnormal male factors contributing to infertility. | • Plans that provide pregnancy-related benefits must cover the cost of 3 IVFs per life birth. • Lifetime $100,000 maximum. • Does not include storage of sperm or oocytes. | 1. Self-funded ERISA plans 2. Religious employers 3. Employers with fewer than 50 employees | |
| 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. | • Plans shall provide for the diagnosis and treatment of infertility including the following: artificial insemination; IVF; GIFT; sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or inseminated eggs, to the extent such costs are not covered by the donor’s insurer, if any; ICSI; ZIFT; assisted hatching; cryopreservation of eggs. • No exclusions, limitations or other restrictions on coverage of infertility drugs that are different from those imposed on any other prescription drugs. • Prohibition on imposing deductibles, copayments, coinsurance, benefit maximums, waiting periods or any other limitations on coverage for required infertility benefits which are different from those imposed upon benefits for services not related to infertility. | Self-insured ERISA plans | |
| Infertility is not defined. Iatrogenic infertility is defined as an impairment of fertility caused by surgery, radiation, chemotherapy, or any other medical treatment affecting reproductive organs or processes. | Plans must provide coverage for oocyte and sperm preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility to an insured. | 1. Self-funded ERISA plans 2. Religious employers 3. Disability income, hospital indemnity, accident-only, vision, dental, or long-term care policies. | |
| Disease caused by an illness, injury, underlying disease, or condition, where an individual’s ability to become pregnant or to carry a pregnancy to live birth is impaired, or where an individual’s ability to cause pregnancy and live birth in the individual’s partner is impaired. | • Plans must cover diagnosis of the cause of fertility; medically necessary fertility treatment; and fertility preservation when a person is expected to undergo surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment of fertility. • Prohibition on imposing deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for required infertility benefits which are different from those imposed upon benefits for services not related to infertility. | 1. Self-funded ERISA plans 2. Small Business Health Options Program (SHOP) | |
| Disease, condition or status characterized by any of the following: (a) inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors; (b) need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; (c) patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older. | • Plans that provide pregnancy-related coverage must provide infertility treatment. • May limit coverage to a person who has used all reasonable, less expensive, and medically appropriate treatments. • Does not include storage of sperm or oocytes. | 1. Self-funded ERISA plans 2. Religious employers 3. Employers with fewer than 50 employees | |
| Disease or condition characterized by the incapacity to impregnate another person or to conceive, defined by the failure to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination, or after six months of regular, unprotected sexual intercourse or therapeutic donor insemination for a female thirty-five years of age or older. | • Plans cannot prohibit exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility. • Large plans (100 or more employees) must cover up to 3 IVF cycles. | 1. Self-funded ERISA plans 2. Small employers (fewer than 100 employees) | |
| No definition provided; law covers infertility services when they are “medically necessary.” | • Plans are required to cover “basic health care services” including infertility services, when they are medically necessary. • IVF, GIFT, and ZIFT are not required by the law. | Self-funded ERISA plans. | |
| Impairment of fertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment with a potential side effect of impaired fertility as established by the American Society of Clinical Oncology or the American Society for Reproductive Medicine. | Beginning January 1, 2025, any plan shall provide coverage for standard fertility preservation services only for individuals diagnosed with cancer and who are within reproductive age, when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. | 1. Self-funded ERISA plans 2. Religious employers that submit and receive written exemption requests | |
| Condition of an otherwise presumably healthy individual who is unable to conceive or produce conception during a period of one year. Iatrogenic infertility means an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. | • Plans that cover pregnancy benefits, must provide coverage for medically necessary expenses of diagnosis and treatment of infertility and for standard fertility preservation services. • For women ages 25-42, coverage is provided for diagnosis and treatment of infertility. • Cost cap of $100,000 for treatment. • Insurance carrier may impose up to a 20% co-payment. | Self-funded ERISA plans | |
| Person and spouse have a history of infertility of at least five continuous years or associated with endometriosis, DES, blockage of or surgical removal of one or both fallopian tubes or oligospermia; covered person has been unable to attain a pregnancy through less costly treatment covered under their policy. | Law requires insurers to offer coverage of IVF, but employers may choose whether or not to include coverage as part of their plan. | 1. Self-funded ERISA plans 2. Religious employers | |
| (a) Patient’s physician verifies that the patient or the patient’s spouse has a demonstrated condition recognized by a physician as a cause of infertility, or the patient attests that the patient is unable to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception. (b) Individuals that have one of the following conditions: Cystic fibrosis, spinal muscular atrophy, Morquio syndrome, myotonic dystrophy, or sickle cell anemia. (c) Patient attests that the patient has been unable to attain a successful pregnancy through any less-costly, potentially effective infertility treatments for which coverage is available under the health benefit plan. | 3-year pilot program for Public Health Employees’ Plan; ends December 31, 2024 | Self-funded ERISA plans | |
| Disease, condition, or status characterized by the failure to establish a pregnancy or to carry a pregnancy to live birth after regular unprotected sexual intercourse in accordance with the guidelines of ASRM, a person’s inability to reproduce without medical intervention either as a single individual or with their partner, or a licensed physician’s findings based on a patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing. | • Beginning January 1, 2025, plans must provide coverage for the diagnosis and treatment of infertility. Includes 3 rounds of IVF; standard fertility preservation services; at least 3 complete oocyte retrievals; unlimited embryo transfers from oocyte retrievals; • Prohibition on discrimination on the basis of age, ancestry, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation. • Prohibition on imposing deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for required infertility benefits that are different from those imposed upon benefits for services not related to infertility. | Self-funded ERISA plans | |
| No definition provided. | Plans must cover infertility services under “basic health services.” | Self-funded ERISA plans |
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Publish Date:Oct 10, 2024Categories:Employee Benefits