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How to Find Out if the New York State IVF Insurance Mandate Applies to You

“Does my employer have to cover IVF now?”

“How can I tell if I have IVF benefits under the new law?”

“I want to do IVF but don’t know if my insurance has to cover it!”

That’s what millions of New Yorkers are wondering. And asking three specific questions will determine the answer.

Many current RMA Long Island IVF patients and prospective patients were eager to flip the calendar on January 1, 2020 because that was the date New York State’s new IVF insurance mandate law went into effect.

If you are suffering from fertility challenges and need vitro fertilization or “IVF” in order to build your family-- but don’t have IVF insurance coverage or the money to self-pay--the new law could be a game changer in your quest for a baby…or two…or maybe even three.

With the generous mandated IVF coverage, plus skilled doctors and a little luck, millions of New Yorkers who could not afford IVF now have the chance to build their entire family—one pregnancy at a time-- over time. Just like the fertile folks do.

What is the IVF insurance law in New York State?

In a nutshell, the mandate requires certain New York-based companies with large group insurance providers to cover up to three IVF cycles for those employees who have been diagnosed with infertility. Other than same-sex male couples — who unfortunately can’t satisfy the current statutory definition of “infertility”— straight and other LGBT couples and singles with a medical diagnosis of infertility can take advantage of this valuable benefit.

Before checking with your or your spouse’s Human Resources department, there are a few scenarios under which the mandate will not apply to you and/or your employer:

  • Same-sex male couples
  • people on Medicaid
  • people on Obamacare health plans through the New York Exchange
  • companies with self-insured plans (usually 1000+ employees)
  • companies with fewer than 100 employees
  • people with individual/self-paid plans
  • people with health insurance provided by the federal government.

Bigger is not always better. Not all large companies with 100 or more employees will be mandated to cover IVF. Many very large companies of 1000 employees or more are not “fully insured”, but rather are “self-insured” --and as such are exempt from state laws, including the IVF mandate. But if your coverage is self-insured and does not include IVF benefits, you can always ask your employer to offer IVF coverage, they just aren’t required to do so. Resolve, the National Infertility Association, offers guidance on how to ask your employer to add IVF coverage.

How can I find out if my employer is required to provide IVF benefits?

Ask your Human Resources benefits representative the following three questions. If all of the answers are “yes”, and you have a medical diagnosis of infertility, then your employer must cover IVF under the new IVF mandate in New York.

  1. Does the employer qualify as a large group with 100 or more employees?
  2. Is the employer New York-based with an insurance policy written in and controlled by New York State?
  3. Is the coverage plan fully-insured?

What else should I know?

If your employer is mandated to offer IVF under the new law:

  • Prescription drugs for the IVF procedure(s) are covered—even if your insurance plan does not otherwise include prescription drug coverage.
  • Embryo freezing, egg freezing, and storage costs are covered.
  • There are no age limits on IVF coverage.
  • There are no annual dollar limitations on IVF services.
  • Frozen embryo transfers count towards the three IVF cycles.
  • IVF treatments completed prior to January 1, 2020 do not count toward the three allowed IVF cycles.
  • IVF services may be subject to co-pays, deductibles, and co-insurance.
  • If the policy offers out-of-network coverage, then out-of-network coverage must be offered for IVF services.
  • Insurers aren’t required to offer IVF to those who underwent prior voluntary sterilization procedures.

The new law also mandates that most insurers-- regardless of plan size—must pay for fertility preservation treatments, like egg or sperm freezing, in cases where people are facing infertility caused by medical interventions that will “directly or indirectly result in ‘iatrogenic infertility’, which is an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes”. Those facing fertility-robbing cancer treatments or considering gender reassignment surgery or other treatment/surgery that can impair their fertility may now be able to freeze their eggs or sperm prior to that treatment or surgery. Ask your HR department if your plan qualifies for these services.

If you are one of the millions of employees in New York expected to benefit from the new IVF mandate, you’re probably excited to take the next step in starting or expanding your family. With the financial obstacle to IVF behind you, the dream of a baby may feel attainable again. RMA Long Island IVF is ready to help you move forward with your family-building plan. Please contact the office to schedule a consultation with one of our RMA Long Island IVF physicians and reach out to our financial counselors with any questions.