In Vitro Fertilization (IVF) is a medical procedure where an egg is fertilized by sperm outside the body and the resulting embryo is transferred to the uterus. Navigating the costs is complex, but New York State mandates insurance coverage for fertility services to make treatment more accessible for those diagnosed with infertility. This article clarifies the specific requirements, limitations, and financial implications of New York’s fertility coverage mandate.
The Foundation of Coverage in New York
New York’s insurance mandate for fertility services took effect on January 1, 2020, significantly expanding required coverage. This legal requirement is codified in the New York Insurance Law (sections 3221 and 4303), compelling certain insurers to cover medically necessary diagnostic and treatment procedures for infertility.
Infertility is defined as the inability to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination. For women 35 or older, this period is shortened to six months. The law prohibits discrimination in coverage based on age, sex, sexual orientation, marital status, or gender identity.
Which Insurance Plans Must Offer Coverage
The requirement to cover a full course of IVF is not universal, depending on the employer’s size. The mandate for up to three full cycles of IVF applies specifically to large group insurance policies, defined as those covering employers with 100 or more employees.
Small group plans (fewer than 100 employees) and individual plans are not required to offer IVF coverage. However, all commercial markets must cover diagnostic testing and basic treatments like intrauterine insemination (IUI). Self-funded plans, often used by very large employers, are governed by federal ERISA law and are exempt from all state-level insurance mandates, including the New York IVF requirement.
All commercial plans must also provide coverage for fertility preservation services. This applies when a medical treatment is likely to cause “iatrogenic infertility,” meaning infertility caused by surgery, chemotherapy, or radiation. Preservation coverage, such as egg or sperm freezing, is required for patients undergoing cancer treatment, gender-affirming care, or other medical interventions that affect reproductive capacity.
Covered Treatments and Mandated Limitations
The mandate requires large group plans to cover up to three full cycles of in vitro fertilization over a patient’s lifetime. A “cycle” includes all treatment starting with preparatory medications for ovarian stimulation or endometrial preparation, encompassing both fresh and frozen embryo transfers. Coverage must also include prescription drugs approved by the Food and Drug Administration used in the diagnosis and treatment of infertility.
The law does not impose age restrictions or allow for annual dollar limitations on mandated services. The plan must cover the egg retrieval, associated anesthesia, laboratory work for fertilization and embryo culture, and the embryo transfer. Coverage also includes embryo freezing, egg freezing, and storage costs associated with the covered IVF cycles.
Insurers can still impose certain limitations, such as requiring a formal infertility diagnosis before covering treatment. Some insurers may require a patient to attempt less invasive procedures, such as IUI, before approving IVF. Coverage is explicitly not required for the reversal of elective sterilization procedures, such as a vasectomy or tubal ligation.
The anti-discrimination provisions ensure that same-sex female couples and single women are covered, as the definition of infertility includes failure to conceive after therapeutic donor insemination. However, the law does not explicitly provide a pathway for same-sex male couples who require both an egg donor and a gestational carrier, resulting in a gap in coverage for this specific family-building path.
Understanding Patient Financial Responsibility
Even with a comprehensive mandate, “covered” does not mean the treatment is entirely free, as patients are still responsible for standard cost-sharing. The financial obligation typically involves deductibles, copayments, and co-insurance, consistent with what the plan charges for other medical services. A patient may need to meet a yearly deductible before the insurance begins to pay for the IVF cycle costs.
Copayments are required for office visits and prescription medications, while co-insurance represents a percentage of the total cost the patient must pay after the deductible is met. Costs for services frequently not covered include elective procedures, such as preimplantation genetic testing (PGT) of embryos. Storage fees for frozen eggs or embryos beyond the initial period covered by the mandate may become the patient’s responsibility.
Patients should confirm network participation, as using an out-of-network fertility clinic can lead to significantly higher out-of-pocket costs. If the policy offers out-of-network benefits for other medical care, it must also offer them for IVF services, though these typically come with higher co-insurance and a separate, higher out-of-network deductible. Understanding the specific cost-sharing structure of one’s plan is important before beginning fertility treatment.