On Sept. 29, 2024, Gov. Gavin Newsom signed Senate Bill (SB) 729. which will require large group health care service plans to cover infertility and fertility services, including in vitro fertilization (IVF), beginning July 1, 2025.
Highlights
Key changes made by SB 729 include the following. The law:
- Revises the definition of infertility and removes the exclusion of IVF from coverage;
- Requires coverage for a maximum of three completed oocyte retrievals;
- Eliminates a requirement that a health plan provide infertility treatment under agreed-upon terms that are communicated to all group contract holders and policyholders; and
- Prohibits a health plan from placing different conditions or coverage limitations on fertility medications or services than those that would apply to other conditions.
Definition of Infertility
For purposes of the coverage mandate, “infertility” means a condition or status characterized by any of the following:
- A licensed physician’s findings. based on a patient’s medical, sexual and reproductive history. age, physical findings. diagnostic testing or any combination of those factors.
- A person’s inability to reproduce either as an individual or with their partner without medical intervention.
- The failure to establish a pregnancy or to carry a pregnancy to live birth after regular. unprotected sexual intercourse. This means no more than 12 months of unprotected sexual intercourse for a person under 35 years of age or no more than six months of unprotected sexual intercourse for a person 35 years of age or older. Pregnancy resulting in miscarriage does not restart the 12- month or six-month time period to qualify as having infertility. The definition cannot prevent testing and diagnosis of infertility before the 12-month or sixmonth period to establish infertility.
Covered Health Care Plans
- Large group health care service plans are generally those that cover over 100 people.
- While small group plans will not be required to cover such services, they will be required to offer such coverage beginning July 1, 2025.
- The coverage mandate does not apply to plans sponsored by religious employers, or to Medi-Cal managed health care service plans.
Large group health plans will be required to cover infertility and fertility services, including /VF, beginning July 1, 2025.
Conclusion
Insured plans will be impacted by this rule, although changes to federal law impacting even self-funded plans could occur. With the new administration, it would be hard to say whether expansion of the Affordable Care Act and its mandates could likely occu. Insured plans sitused in California should work with their Leavitt Group Trusted Advisor to ensure plans include this mandatory coverage.
Source: Zywave. Republished with permission. Some content by Leavitt Group.