Who’s covered by Colorado’s new IVF insurance requirement?

Starting in January, some Colorado residents’ health insurance will pay for in-vitro fertilization, but like many of the state’s efforts to expand coverage, it doesn’t apply to everyone.

House Bill 1008, which passed this spring, requires state-regulated large-group employer health plans to cover the full range of services to treat infertility. People with other types of health insurance may have some coverage, but are more likely to run into limits.

Here are answers to some common questions about the new law:

How will I know if this applies to me?

First, check your insurance card. If it says “CO-DOI” somewhere on the card, your insurance plan is state-regulated. If not, the new mandate doesn’t apply to you. That was also the case with other coverage requirements the state set in recent years, like the cap on out-of-pocket costs for insulin.

Only large-group plans regulated by the Colorado Division of Insurance fall under the new mandate, though. You can’t tell by looking at the card if your insurance plan is large-group or small-group, so you’ll need to call either your employer’s human resources department or your insurance company to be sure.

Religious organizations are allowed to ask their insurance plans not to cover certain fertility services they object to, but are required to notify employees if they do so.

If you’re covered by Medicaid or another form of government-provided insurance, the mandate doesn’t apply to you.

I’m covered. What does that mean?

Starting in January, you have coverage for fertility services deemed appropriate under the American Society of Reproductive Medicine’s guidelines. That can include preventive services, like freezing eggs before a woman undergoes cancer treatment.

For people who need in-vitro fertilization, insurance will have to cover three egg retrievals and unlimited attempts to transfer an embryo. IVF involves stimulating the ovaries with drugs to produce more eggs, which are removed and fertilized outside the body with sperm from a partner or donor. They’re then transferred into the body, hopefully resulting in a pregnancy and healthy birth.

Plans aren’t allowed to put restrictions on medications used for infertility beyond what they have for other drugs, and can’t set a separate deductible or require higher out-of-pocket payments. That still leaves room for variation, though: a household with a high-deductible insurance plan is almost certainly going to pay more out-of-pocket for infertility care than one that pays higher monthly premiums in exchange for lower costs when they use care.

The mandate uses the American College of Obstetricians and Gynecologists’ definition of infertility, which is an inability to conceive after one year of regular sex without contraception for women under 35 and six months without success for older women. It also allows for coverage if a physician diagnoses infertility some other way.

My plan isn’t under the mandate. Do I have any coverage?

Some infertility services have been considered an essential health benefit in Colorado since 2017. That means individual and small-group plans have to cover the testing to diagnose infertility, as well as artificial insemination, without extra barriers or costs.

They don’t have to cover IVF or egg-freezing to prevent infertility. It’s not common, but some companies opt to add more infertility coverage, so check with your insurance provider before you start treatment.

It’s possible that you’ll have additional coverage at some point in the future, if the U.S. Department of Health and Human Services signs off.

Why do only some plans need federal approval?

The Colorado Division of Insurance gets to decide whether any expansion of coverage constitutes a new mandate when it comes to state-regulated large-group plans. It determined that requiring more fertility services to be covered fell under the existing requirement to cover maternity care.

For individual and small-group plans, the U.S. Department of Health and Human Services has to agree that it’s not a new mandate. A different bill requiring expanded fertility coverage passed in 2020 and sent the proposal to HHS for approval, but the department didn’t agree with the state and threw it out as a new mandate.

The 2022 bill basically broke out the state-regulated plans (which don’t require federal approval) to give some people coverage starting in January. The insurance division is still working on convincing HHS that it should approve coverage of more fertility services for people with individual and small-group insurance.

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