In Vitro Fertilization (IVF) is a complex medical procedure where an egg is fertilized by sperm outside the body, with the resulting embryo then transferred into the uterus. Connecticut is one of a growing number of states that has mandated insurance coverage for infertility diagnosis and treatment, including IVF, through state law. This state mandate requires certain health insurance plans to cover a defined range of services. Understanding which plans are subject to this requirement and the specific limits of the coverage is the first step in navigating the process.
Determining Which Insurance Plans Must Cover IVF
The applicability of Connecticut’s infertility mandate depends heavily on the type of health insurance plan an individual holds. The mandate applies to group and individual health insurance policies that are considered “fully-insured” and are delivered or issued for delivery in Connecticut. In a fully-insured plan, the employer pays premiums to an insurance company, and the insurer bears the financial risk for all employee medical claims. Fully-insured plans are required to comply with state benefit mandates.
Conversely, many large employers utilize “self-funded” or “self-insured” health plans, which are exempt from state mandates under the federal Employee Retirement Income Security Act (ERISA). With a self-funded plan, the employer pays for employee medical claims directly, often contracting with an insurance company only to administer the benefits. Because these plans are regulated federally, they are not obligated to follow Connecticut’s state-level coverage requirements for IVF. Individuals must contact their human resources department or insurance carrier to verify whether their plan is fully-insured and therefore subject to the state mandate.
The Specific Services Mandated for Coverage
The Connecticut mandate requires covered plans to provide comprehensive coverage for the medically necessary expenses of diagnosing and treating infertility. This scope includes a variety of related assisted reproductive technologies (ART). Diagnostic services, including the initial evaluation and testing to determine the cause of infertility, are also covered under the mandate.
The law mandates coverage for procedures including ovulation induction and artificial insemination methods like intrauterine insemination (IUI). More complex procedures are also covered:
- Gamete intrafallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
- Uterine embryo lavage
- Embryo transfer
- Low tubal ovum transfer
Requirements and Financial Limits for Accessing Treatment
To access the mandated coverage, the patient must first meet the state’s definition of infertility. This generally means the inability to conceive or sustain a successful pregnancy during a one-year period. Coverage is also allowed if the treatment is determined to be medically necessary, providing a pathway for individuals who have not yet completed the full one-year period. Age is considered only as part of a medical necessity determination based on clinical guidelines, as previous blanket age limitations have been eliminated.
The mandate sets lifetime maximum limits on the number of treatment cycles. Plans may limit coverage to a maximum of four cycles of ovulation induction and three cycles of intrauterine insemination (IUI). For IVF, GIFT, or ZIFT, plans may impose a lifetime maximum of two cycles. Each IVF cycle includes the egg retrieval and subsequent embryo transfers, limited to not more than two embryo implantations per transfer.
Practical Steps for Utilizing IVF Coverage
Navigating the administrative process is important for utilizing the mandated IVF coverage. The first action should be to contact the insurance carrier or human resources department to confirm the plan is fully-insured and subject to the Connecticut mandate. Requesting a copy of the specific policy manual regarding infertility benefits is helpful to understand plan-specific stipulations, such as deductibles, co-payments, and co-insurance that still apply.
Securing a pre-authorization or pre-certification from the insurance company is required before treatment begins. This administrative step verifies that the proposed treatment is considered medically necessary and covered under the policy. Providers typically require comprehensive documentation, including medical records and diagnostic test results, to submit with the pre-authorization request. If a claim is initially denied, the patient has the right to follow the insurer’s internal appeal process and may also be eligible for an external review.