In Vitro Fertilization (IVF) is a complex medical procedure where an egg is fertilized by sperm outside the body in a laboratory setting. The resulting embryo is then transferred into the uterus to establish a pregnancy. Due to the substantial costs associated with this process, access to IVF often depends heavily on insurance coverage. Connecticut is one of a limited number of states that mandates insurance coverage for medically necessary infertility treatment. This mandate creates a legal framework for coverage, but specific rules determine who is covered and what benefits are provided.
The Connecticut State Mandate
Connecticut’s requirement for infertility coverage is rooted in state law that defines infertility as a medical condition requiring diagnosis and treatment. The original legislation was passed in October 2005, recognizing that the inability to conceive is a disease. This mandate applies to individual and group health insurance policies delivered or renewed within the state.
The law ensures that medically necessary expenses for the diagnosis and treatment of infertility are covered by certain insurance plans. This requirement is codified in the Connecticut General Statutes, specifically sections C.G.S. §§ 38a-509 and 38a-536. The mandate requires insurers to cover a range of services, including evaluation and testing, as part of the overall treatment plan.
Which Plans Must Provide Coverage
The applicability of the Connecticut mandate is the most important factor in determining if a policy covers IVF. State law only has jurisdiction over fully insured health plans, where an employer purchases a policy from an insurance carrier. In these plans, the insurance company assumes the financial risk of paying claims and must comply with all state-level mandates.
Many employers, particularly large corporations, utilize self-funded health plans, which are exempt from state insurance mandates. Under a self-funded plan, the employer assumes the financial risk and pays employee health claims directly. These plans are governed by federal law, specifically the Employee Retirement Income Security Act (ERISA), and are not required to adhere to Connecticut’s IVF mandate.
To determine coverage, an individual must understand how their employer finances the benefits. If the employer pays monthly premiums to an insurer, the plan is likely fully insured and subject to the mandate. If the employer pays claims out of its own operating funds, the plan is likely self-funded and exempt. Connecticut law also allows religious employers to apply for an exemption if coverage conflicts with their bona fide religious tenets.
Specific Coverage Requirements and Limitations
For health plans subject to the Connecticut mandate, coverage for infertility treatment is comprehensive but includes specific limitations on the number of cycles. The law defines infertility as the condition of an individual who is unable to conceive or sustain a successful pregnancy during a one-year period, or when treatment is otherwise medically necessary. This definition ensures coverage is available for a range of circumstances, including those with pre-existing medical conditions that prevent conception.
The mandate requires covered plans to provide specific lifetime maximums for treatment cycles. These preliminary treatments must generally be attempted first, unless a physician determines they are unlikely to be successful due to a specific medical diagnosis. The required lifetime maximums include:
- Two In Vitro Fertilization (IVF) cycles, limited to no more than two embryo implantations per cycle.
- Four cycles of ovulation induction.
- Three cycles of intrauterine insemination (IUI).
Initial versions of the law included a blanket age limit, but this restriction was removed for policies sold or renewed after January 1, 2016. Coverage can no longer be denied solely based on the patient’s age. However, the medical necessity of the treatment is still reviewed using clinical guidelines, meaning age remains a factor in a physician’s assessment. Covered services include the core IVF process, diagnostic testing, and fertility preservation for individuals facing medical treatments that may cause infertility. The long-term storage of eggs, sperm, or embryos via cryopreservation is not required under the mandate and may incur out-of-pocket costs.
Navigating Denials and Appeals
When a covered health plan denies a claim for IVF or related services, the patient has a required process for challenging the decision. The first step involves filing an internal appeal directly with the insurance company, which must be completed before pursuing external review. The denial letter provides specific instructions on how to initiate this process within the stated timeframes.
If the internal appeal is unsuccessful, the patient has the right to request an external review through the Connecticut Department of Insurance (DOI). This process involves an independent third party reviewing the medical necessity determination. The request for external review must be submitted to the DOI within 120 days of receiving the final written decision from the insurer’s internal appeal.
For individuals with self-funded plans, the appeal options are more restricted because the state mandate does not apply. Challenges to a coverage denial for an ERISA-exempt plan must follow the internal process outlined by the employer’s plan documents, which are governed by federal ERISA regulations.