Starting next July, some California residents’ health insurance will pay for in-vitro fertilization, but it doesn’t apply to everyone.
Gov. Gavin Newsom signed a bill on Sunday that requires state-regulated, large-group employer health plans to cover the full range of services to treat infertility. The treatments can be expensive, easily surpassing $15,000, making it unattainable for many.
“California is a proud reproductive-freedom state — and that includes increasing access to fertility services that help those who want to start a family,” Newsom said in a statement Sunday after he signed State Senate Bill 729.
The current state mandate, more than 30 years old, requires group insurers to offer coverage for fertility treatment but excludes IVF.
While polls show a vast majority of Americans support IVF, some conservative groups oppose the procedure. The California Family Council criticized the bill, in part because it covered same-sex couples.
Four earlier efforts to broaden infertility treatment failed in the legislature over the past five years. This bill, co-sponsored by Assemblymember Buffy Wicks, an Oakland Democrat, achieved success after exempting small plans, individual markets and Medi-Cal.
Fifteen states have laws in effect requiring certain health plans to cover at least some infertility treatments, according to the Kaiser Family Foundation. But until now, Colorado is the only state to require coverage of diagnosis, treatment and fertility preservation for age-related infertility.
According to Pacific Fertility Center, “natural IVF,” which involves egg collection in conjunction with a woman’s natural menstrual cycle and does not require medications, ranges from $3,000 to $6,000. Traditional IVF, which typically involves an intensive medication regimen and monitoring process, ranges from $14,000 to $20,000 or more, depending on factors such as location, clinic and additional procedures. That price tag includes medications, monitoring appointments, egg retrieval, fertilization, embryo transfer and other related services.
Here are answers to some common questions about the new law:
Q: How will I know if this applies to me?
A: It requires that large group, state-regulated health plans — that is, employers that cover at least 100 people — provide coverage for the diagnosis and treatment of infertility. An estimated 9 million Californians are enrolled in such plans.
The new law does not apply to people with small group plans, covering 100 or fewer employees, or self-funded or self-insured health insurance plans. While such plans can offer the coverage, it is not required.
It also does not apply to people who get their health coverage from religious employers or people enrolled in Medi-Cal, California’s Medicaid program for low-income adults.
You can’t tell by looking at your insurance card if your plan is eligible, so you’ll need to call your employer’s human resources department or your insurance company to be sure.
Q: Are single people or same-sex couples eligible?
A: Yes. The new law broadens the definition of infertility so that single people who choose to parent alone or freeze their eggs or sperm for future treatment can get services. So can people in a same-sex relationship.
The definition of infertility now includes “a person’s inability to reproduce either as an individual or with their partner without medical intervention.”
Q: What does it cover?
A: It pays for a maximum of three egg retrievals and unlimited embryo transfers during IVF. It also covers sperm testing and sperm deposits, as well as cryopreservation of eggs and embryos for future use.
It caps your lifetime benefits to $75,000.
Q: I’m covered. What does that mean?
A: You can get access to fertility services deemed appropriate under the American Society of Reproductive Medicine’s guidelines if you are unable to become pregnant or carry a pregnancy to term after regular, unprotected sexual intercourse.
Depending on your policy, you may still be responsible for deductibles and co-pays toward the treatment.
Q: How is “infertility” defined?
A: It means that you haven’t conceived after 12 months of unprotected sexual intercourse, if you’re younger than 35 years of age, or 6 months of unprotected sexual intercourse if you’re age 35 or older.
Q: When does it go into effect?
A: The law will go into effect in July 2025 for most beneficiaries and in July 2027 for government workers who get their health benefits from the California Public Employees’ Retirement System, or CalPERS.
This delay in implementation allows the state legislature to evaluate whether to keep the law as is or match what the state decides to include in its “essential health benefits” benchmark plan, now being developed. When the new benchmark plan takes effect, it is possible that everyone in the fully insured market — even if in an individual or small group plan — would have IVF insurance coverage But the specifics of that coverage are not yet known.
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