The financial burden of fertility treatment, particularly In Vitro Fertilization (IVF), often places it out of reach for many. Maryland stands as one of the few states in the nation that mandates health insurance providers to cover the costs associated with fertility care. This state-level requirement aims to improve accessibility to services like IVF, making the path to parenthood less dependent on income. Understanding the specifics of this mandate is the first step for residents seeking to utilize this coverage.
The Legal Foundation of Coverage
The requirement for insurance coverage of fertility services in Maryland is established by state statute, specifically Maryland Code, Insurance Article, § 15-810. This law defines the scope of required benefits and sets the parameters for patient eligibility. The goal of the legislation is to categorize infertility as a medical condition requiring treatment, rather than a voluntary procedure.
The statute provides a clinical definition of infertility that triggers mandated coverage. For an opposite-sex couple, this is defined as the inability to achieve a successful pregnancy after one year of unprotected sexual intercourse. The law was updated in 2021 to accommodate same-sex couples and unmarried individuals, for whom the standard is three failed attempts at artificial insemination over one year.
Alternatively, a patient may qualify for coverage if their infertility is associated with a specific medical diagnosis. Examples include endometriosis, exposure to diethylstilbestrol (DES), or the surgical removal or blockage of one or both fallopian tubes. Abnormal male factors, such as oligospermia, also meet the medical criteria for mandated coverage. This legal framework ensures that the diagnosis of infertility is based on objective, clinical measures.
Insurance Plans Subject to the Mandate
Determining if a health plan must comply with the Maryland mandate hinges on the type of insurance and where it was issued. The law applies broadly to health maintenance organizations (HMOs) and fully-insured plans, including individual and group policies, that are issued or delivered in Maryland. A fully-insured plan is one where the employer pays a set premium to an insurance company, and the insurer takes on the risk of paying claims.
A distinction exists for self-funded, or self-insured, employer health plans. These plans are governed by the federal Employee Retirement Income Security Act (ERISA) and are exempt from state insurance mandates, including Maryland’s IVF coverage law. Since the employer assumes the financial risk for paying claims, state regulations cannot dictate the benefits offered.
This ERISA exemption is the most common reason why an individual in Maryland may not have mandated IVF coverage. The mandate also does not apply to small employers, defined as those with 50 or fewer employees. Religious organizations can request an exemption if providing the coverage conflicts with their bona fide religious beliefs.
Defining Covered Treatments and Limits
The Maryland law requires coverage for a range of infertility services, with specific limits imposed on the most costly treatments. The mandate explicitly includes coverage for In Vitro Fertilization procedures. Insurers may place a limit on the number of attempts a patient can receive.
This limit is typically set at three IVF attempts per live birth. An “attempt” is defined as the cycle beginning with medication and monitoring for ovarian stimulation, culminating in an egg retrieval procedure. The law allows insurers to impose a maximum lifetime benefit for all covered fertility services, which cannot exceed $100,000.
Beyond IVF, the mandate requires coverage for other necessary fertility services, such as diagnostic testing, therapeutic procedures, and ovulation induction. This includes Intrauterine Insemination (IUI), a less invasive and costly treatment often required before proceeding to IVF. The law also mandates coverage for standard fertility preservation services for patients facing iatrogenic infertility, which is impairment caused by medically necessary treatments like chemotherapy or radiation.
Preimplantation Genetic Testing (PGT) is not explicitly listed as a required covered service under the current statute. While some insurance carriers may voluntarily cover PGT, particularly if there is a documented medical necessity, patients should confirm this detail with their specific plan.
Required Patient Eligibility Criteria
Accessing mandated coverage requires patients to meet specific criteria, designed to ensure that the most expensive treatments are medically appropriate. Patients must be a policyholder, a subscriber, or a covered dependent under a qualifying health plan. The law does not impose a maximum age limit for coverage, unlike mandates in some other states.
A requirement is the need to demonstrate failure with less costly, less invasive treatments before IVF coverage begins. Insurers can require a patient to attempt and fail a maximum of three cycles of IUI or ovulation induction before authorizing IVF. This step-therapy approach ensures a progressive treatment strategy is followed, aligning with standard medical practice.
The law stipulates that IVF procedures must be performed at medical facilities that conform to applicable guidelines and minimum standards set by professional organizations. These facilities must adhere to the standards of the American College of Obstetricians and Gynecologists (ACOG) or the American Society for Reproductive Medicine (ASRM). This requirement maintains a standard of quality and safety for the complex procedures involved in fertility care.