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URMC / Obstetrics & Gynecology / Strong Fertility Center / Cost / NY State Insurance Coverage

 

What to Know About NY State Insurance Coverage

1990, 2002, 2020
NY S.B. 6257-B/A.B. 9759-B
NY Insurance Law Sections 3216 (13), 3221
FY 2020 New York State Budget

Definition of Infertility/Patient Requirements

  • Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility.
  • Infertility means a disease or condition characterized by the incapacity to impregnate another person or to conceive, defined by the failure to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination, or after six months of regular, unprotected sexual intercourse or therapeutic donor insemination for a female thirty-five years of age or older. Earlier evaluation and treatment may be warranted based on an individual’s medical history or physical findings.
  • Standard fertility preservation procedures are covered but not defined by law.

Coverage

Group policies must provide diagnostic tests and procedures that include:

  • hysterosalpingogram;
  • hysteroscopy;
  • endometrial biopsy;
  • laparoscopy;
  • sonohysterogram;
  • post coital tests;
  • testis biopsy;
  • semen analysis;
  • blood tests, and
  • ultrasound.
  • Provides up to 3 IVF cycles (fresh embryo transfer or frozen embryo transfer) to patients in the large group insurance market (100 or more employees).
  • Provides medically necessary fertility preservation medical treatments for people facing iatrogenic infertility caused by a medical intervention, such as radiation, medication, or surgery, in all commercial markets (individual, small and large groups).
  • Every policy that provides for prescription drug coverage, shall also include drugs (approved by the FDA) for use in the diagnosis and treatment of infertility.
  • Prohibits delivery of insurance coverage from discriminating based on age, sex, sexual orientation, marital status, or gender identity.

Exceptions

  • Excludes coverage for IVF in the individual and small group markets, GIFT, and ZIFT; reversal of elective sterilizations; sex change procedures; cloning or experimental medical or surgical procedures.
  • Employers who self-insure are exempt from the requirements of the law.