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Is there a law in NJ or Mass that mandates insurance ...

Customer Question

Is there a law in NJ or Mass that mandates insurance companies to cover fertility treatment? How can a company get around this & not offer coverage?
Submitted: 6 years ago.
Category: Legal
Expert:  LawHelpNow replied 6 years ago.

Hello and thanks so much for choosing this forum to pose your important legal question. I will do my best to give you some honest and accurate guidance.

Massachusetts

This state's law requires health maintenance organizations and insurance companies that cover pregnancy-related benefits to cover medically necessary expenses of infertility diagnosis and treatment. The law defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period."

Benefits covered include:

  • Artificial insemination;
  • In vitro fertilization;
  • Gamete Intrafallopian Transfer;
  • Sperm, egg and/or inseminated egg retrieval, to the extent that those costs are not covered by the donor's insurer;
  • Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility; and
  • Zygote Intrafallopian Transfer (ZIFT).

Insurers may, but are not required, to cover experimental procedures, surrogacy, reversal of voluntary sterilization or cryopreservation of eggs. (Annotated Laws of Massachusetts, Chapters 175,§ 47H; 176A,§8K;176B,§4J; and l76G,§4, 211 CMR 37.00).

New Jersey

The Family Building Act requires insurance policies that cover more than 50 people and provide pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility. The law defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex (female partner under the age of 35) or one year of unprotected sex (female partner over the age of 35) or the inability to carry a pregnancy to term.

Coverage includes, but is not limited to:

  • Diagnosis & diagnostic tests

  • Medications

  • Surgery

  • In vitro fertilization (IVF)

  • Embryo transfer

  • Artificial insemination

  • Gamete intra fallopian transfer (GIFT)

  • Zygote intra fallopian transfer (ZIFT)

  • Intracytoplasmic Sperm Injection (ICSI)

  • Four completed egg retrievals per lifetime

Coverage for IVF, GIFT and ZIFT is required only if:

  • The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;

  • The patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger.

  • The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

The law allows religious organizations to request an exclusion of this coverage if it is contrary to the religious employer's bona fide religious tenets. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48E-35.22 Health Service Corporations; 26:2J-4.23 Health Maintenance Organizations)

If we can be of any further assistance please free to use our service again. Best wishes for a successful outcome.

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The information provided is general in nature only and should not be construed as legal advice. By using this forum, you acknowledge that no attorney-client relationship has been created between you and Benjamin M. Burt, Jr., Esq. You should always consult with a lawyer in your state.

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