Biden administration considering IVF coverage requirement, fertility definition change

Some health plans may soon be federally required to cover fertility treatments for members, regardless of their sexual orientation or gender identity, according to Bloomberg Law.

Many payers base eligibility for fertility treatment coverage on the CDC definition of infertility:  "not being able to get pregnant (conceive) after one year (or longer) of unprotected sex."

The definition often excludes same-sex couples from fertility treatment coverage since pregancy cannot occur from unprotected sex between two women or two men.

The Biden administration may change the definition of infertility for some group health plans and plans covered under the Affordable Care Act. The changes would apply after a notice-and-comment process, according to Bloomberg.

HHS may also clarify that state-mandated coverage of fertility treatments is an "essential health benefit," meaning states would not be responsible for the added cost to payers.

The changes would occur under Section 1557 of the ACA as it applies to fertility treatment. The Office of Management and Budget has scheduled meetings with advocates and opponents through May 17. Changes to Section 1557 would apply to about 10.8 percent of Americans with health insurance, including about 18.7 million people with individual market plans, and 12.8 million on small group plans as of 2019.

The changes or any state mandates would not apply to self-funded employer plans, or about 67 percent of employees nationwide.

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