Colorado’s mandate for IVF coverage begins in January. Here’s what you need to know. – InsuranceNewsNet

Since January some Colorado residents’ health insurance will pay for IVF, 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 health plans for large employer groups to cover the full range of infertility treatment services. People with other types of health insurance may have some coverage, but are more likely to run into limitations.

Here are answers to some frequently asked questions about the new law:

How do I know if this applies to me?

Check your insurance card first. If it says “CO-DOI” anywhere on the card, your insurance plan is state-regulated. If not, the new mandate does not apply to you. That was also the case with other state-imposed coverage requirements in recent years, such as the cap on out-of-pocket insulin costs.

Only large group plans regulated by Colorado Department of Insurance still fall under the new mandate. You can’t tell by looking at the map whether your insurance plan is for a large group or a 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 staff if they do.

If you are covered by Medicaid or another form of government-provided insurance, the mandate does not apply to you.

I’m covered. What does this mean?

From January you have cover for fertility services that are considered suitable under American Society for Reproductive Medicine guidelines. This may include preventive services, such as freezing eggs before a woman undergoes cancer treatment.

For people who need IVF, insurance will need to cover three egg retrievals and an unlimited number of embryo transfer attempts. 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 are then transferred into the body, hoping to lead to pregnancy and a healthy birth.

Plans are not allowed to place limits on drugs used for infertility beyond what they have for other drugs, and they cannot set a separate deductible or require higher out-of-pocket payments. However, this still leaves room for variation: A household with a high-deductible insurance plan will almost certainly pay more out-of-pocket for infertility care than a household that pays higher monthly premiums in exchange for lower costs when uses care.

The mandate uses American College of Obstetricians and Gynecologists definition of infertility, which is the 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 coverage if the doctor diagnoses infertility in another way.

My plan is not under the mandate. Do I have any coverage?

Some infertility services are considered a significant health benefit Colorado since 2017. This means that individual and small group plans must cover infertility testing as well as artificial insemination, without additional barriers or costs.

They should not cover IVF or egg freezing to prevent infertility. It’s not common, but some companies choose to add more coverage for infertility, so check with your insurance provider before starting treatment.

You may have additional coverage at some point in the future if US Department of Health and Human Services is signed off.

Why do only some plans need federal approval?

Colorado Department of Insurance must decide whether any expansion of coverage constitutes a new mandate when it comes to state-regulated large group plans. It determined that the requirement to cover more fertility services falls within the existing requirement to cover maternity care.

For individual and small group plans, US Department of Health and Human Services must agree that this is not a new mandate. Another bill requiring expanded fertility coverage passed in 2020 and sent the proposal to HHS for approval, but the department disagreed with the state and rejected it as a new mandate.

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

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