In Vitro Fertilization (IVF) is a complex medical procedure involving the creation of embryos in a laboratory for transfer to the uterus. Due to the significant financial burden of this treatment, New York State enacted specific laws mandating insurance coverage for fertility care. While the New York mandate is not universal, understanding which policies are subject to the state’s requirements is the first step toward accessing this benefit.
New York State Mandatory Coverage Requirements
The obligation for insurers to cover IVF in New York is established by state law, targeting specific categories of state-regulated policies. The primary mandate falls on fully insured “large group” policies, which are health plans offered by employers with 101 or more employees.
Determining if a policy is “fully insured” and regulated by New York is essential. Self-funded plans, often offered by large national companies, are regulated by federal law under the Employee Retirement Income Security Act (ERISA). These ERISA-governed plans are exempt from state mandates and are not required to include the IVF benefit.
The law does not extend the IVF mandate to small group plans (100 or fewer workers) or individual health insurance policies. Federal plans, such as those for military personnel or government employees, and Medicaid are also exempt from the state’s IVF coverage mandate.
Covered Treatments and Services
The New York mandate defines the scope of services covered under qualifying large group plans, requiring insurers to cover up to three lifetime cycles of IVF. A single cycle is defined comprehensively, encompassing all treatment from preparatory medications for ovarian stimulation and oocyte retrieval, or medications used for endometrial preparation for a frozen embryo transfer.
Coverage includes necessary prescription drugs associated with the three IVF cycles, even if the policy lacks a separate drug benefit. The process also covers the costs of egg retrieval, embryo creation, and the freezing and storage of eggs or embryos when medically necessary as part of the mandated cycles.
A separate, broader mandate for fertility preservation applies to all individual, small, and large group policies. This provision requires coverage for the collection, freezing, and storage of eggs or sperm when a patient faces “iatrogenic infertility.” This is defined as fertility impairment caused by medical treatment, such as chemotherapy, radiation, or certain surgeries.
Patient Eligibility and Coverage Limits
To qualify for mandated IVF coverage, an individual must receive a physician’s diagnosis of infertility. State law defines infertility based on the duration of attempts to conceive. For women under 35, this is defined as the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or therapeutic donor insemination.
This diagnostic period is shortened to six months for women aged 35 or older. Earlier evaluation and treatment are permitted if a patient’s medical history indicates a need for immediate intervention. The law prohibits insurance providers from discriminating based on personal characteristics, including age, sexual orientation, marital status, or gender identity, when determining eligibility.
The state mandate imposes a maximum limit of three IVF cycles over a patient’s lifetime under the qualifying large group policy. Both started but incomplete cycles and frozen embryo transfers count toward this limit. The law forbids imposing age restrictions or annual dollar maximums on the benefit, ensuring the three cycles can be fully utilized regardless of cost.
Navigating Your Coverage and Costs
The first step in utilizing the New York mandate is confirming if your health plan is subject to the law. Ask your human resources department or insurance company if your policy is a fully insured, state-regulated large group plan, or a self-funded plan exempt from state mandates. This distinction verifies eligibility for the three-cycle benefit.
Even with mandated coverage, patients should be prepared for standard out-of-pocket costs. The law does not require plans to eliminate cost-sharing, meaning deductibles, copayments, and coinsurance apply to IVF services like any other medical treatment. Contact your insurer to understand how your policy’s cost-sharing structure applies.
Most insurance carriers require pre-authorization for IVF treatment before services are rendered. This involves your physician seeking approval to confirm the treatment is medically necessary and meets policy criteria, including the infertility diagnosis. Obtaining pre-authorization helps prevent unexpected denial of coverage after treatment has started.