ModifiedConnecticut Insurance DepartmentPolicy HC-64

Infertility Treatment and Procedures Coverage

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This bulletin explains implementation of Connecticut Public Act 05-196, requiring certain Connecticut individual and group health policies to cover medically necessary infertility diagnosis and treatment subject to statutory limits.

Policy Summary

PayerConnecticut Insurance Department

PolicyInfertility Treatment and Procedures Coverage

Policy CodePolicy HC-64

Change TypeModified

Effective DateJanuary 20, 2006

Next Review DateN/A

Key ActionBefore covering IVF, GIFT, ZIFT, or low tubal ovum transfer, confirm that less expensive and medically viable covered infertility treatment has been unsuccessful.

SourceLink

POLICY UPDATE CHANGES

This bulletin modifies and supersedes the September 15, 2005 version of Bulletin HC-64.

The Department states that group carriers should not apply the statutory 12-month infertility-benefit waiting period because it conflicts with HIPAA.

The Department states that prior infertility benefits may not be applied toward subsequent group-plan lifetime maximums or required as a group-policy disclosure because of HIPAA.

40th birthdayMaximum coverage age

4 cyclesOvulation induction maximum

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ModifiedConnecticut Insurance DepartmentPolicy HC-64

Infertility Treatment and Procedures Coverage

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy HC-64 alerts

Get alerted when Policy HC-64 changes without checking for updates manually.

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Policy Summary

PayerConnecticut Insurance Department

PolicyInfertility Treatment and Procedures Coverage

Policy CodePolicy HC-64

Change TypeModified

Effective DateJanuary 20, 2006

Next Review DateN/A

Key ActionBefore covering IVF, GIFT, ZIFT, or low tubal ovum transfer, confirm that less expensive and medically viable covered infertility treatment has been unsuccessful.

SourceLink

POLICY UPDATE CHANGES

This bulletin modifies and supersedes the September 15, 2005 version of Bulletin HC-64.

The Department states that group carriers should not apply the statutory 12-month infertility-benefit waiting period because it conflicts with HIPAA.

The Department states that prior infertility benefits may not be applied toward subsequent group-plan lifetime maximums or required as a group-policy disclosure because of HIPAA.

40th birthdayMaximum coverage age

4 cyclesOvulation induction maximum

3 cyclesIntrauterine insemination maximum

2 cyclesIVF/GIFT/ZIFT transfer maximum

0%-50%Infertility drug coinsurance

$0-$40Infertility drug copay

Mandated Infertility Coverage

Covered when medically necessary and subject to the applicable policy and statutory limitations.

General mandated coverage: The policy is an individual or group health policy of a type covered by the Act and is delivered, issued, amended, renewed, or continued in Connecticut on or after October 1, 2005.Effective on or after October 1, 2005

The mandate applies to specified hospital, medical, major medical, hospital or medical service plan, and health care center coverage.

Medical necessity: The infertility diagnosis or treatment is medically necessary under the policy.Medically necessary

Treatment-protocol and medical-necessity determinations should be reviewed by the carrier's medical director in light of applicable reproductive-medicine standards.

Covered infertility services: The service is infertility diagnosis or treatment, including ovulation induction, intrauterine insemination, IVF, uterine embryo lavage, embryo transfer, GIFT, ZIFT, or low tubal ovum transfer.Listed services are illustrative and not exhaustive

Male infertility treatment is included.

Statutory Coverage Limitations

Coverage is subject to all applicable statutory limits.

Age and cycle limits: The individual remains within the permitted age and lifetime cycle limits for the requested service.Until the fortieth birthday; 4 ovulation-induction cycles; 3 intrauterine-insemination cycles; 2 combined IVF/GIFT/ZIFT/low tubal ovum transfer cycles

The combined two-cycle limit applies across IVF, GIFT, ZIFT, and low tubal ovum transfer, and each fertilization or transfer is credited as one cycle.

Embryo implantation limit: For IVF, GIFT, ZIFT, or low tubal ovum transfer, no more than two embryo implantations are performed per cycle.No more than 2 embryo implantations per cycle

This limit applies within the combined two-cycle maximum.

Qualified facility: The treatment is performed at a facility conforming to ASRM or SREI standards and guidelines.

Individual and Group Plan Administration

Lifetime limits and prior-treatment rules depend on the type of coverage.

Individual policy administration: For an individual policy, prior insured infertility treatment is disclosed using the Insurance Commissioner's prescribed form and may be considered in determining the individual's lifetime maximum.Prior insured treatment during the individual's lifetime

The Department's look-back interpretation includes treatment covered by fully insured policies before October 1, 2005; self-funded-plan services and entirely self-paid services do not count.

Group policy administration: For a group policy, administer the infertility benefit without a separate state-mandated 12-month waiting period and do not apply prior-plan benefits to the current plan's lifetime maximum.No separate infertility-benefit waiting period; no prior-plan lifetime crediting

These positions are based on HIPAA; an overall group-plan eligibility waiting period may still apply.

Donor costs are not mandated coverage under the Connecticut infertility coverage requirements.

Expenses related to pregnancies and deliveries that may result from infertility treatment are not mandated coverage.

Reversal of male or female surgical sterilization is not mandated coverage under the infertility coverage requirements.

Gestational-carrier or surrogate-parenting arrangements are not mandated coverage.

Coverage Limits and Cost Sharing

Coverage age limit

Coverage age limitCoverage may be limited until the individual's fortieth birthday; expenses incurred after that birth date may be excluded.

Ovulation induction

Lifetime maximum4 cycles for ovulation induction.

Intrauterine insemination

Lifetime maximum3 cycles for intrauterine insemination.

IVF, GIFT, ZIFT, and low tubal ovum transfer

Operational Requirements and Denial Risks

Prior Authorization

Confirm Prior Authorization

Check the policy for a disclosed prior authorization requirement before infertility benefits are rendered. Prior authorization may apply only when the requirement is disclosed in the policy.

Step Therapy

Verify Lower-Cost Treatment Prerequisite

Before approving advanced infertility procedures, document that the individual was unable to conceive, produce conception, or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under the policy.

Documentation Required

Collect Prior-Treatment Disclosure

Policy Background

The bulletin defines infertility as the condition of a presumably healthy individual who is unable to conceive, produce conception, or sustain a successful pregnancy during a one-year period. Mandated medically necessary diagnosis and treatment may include ovulation induction, intrauterine insemination, in vitro fertilization, uterine embryo lavage, embryo transfer, GIFT, ZIFT, and low tubal ovum transfer; male infertility treatment is included. Medical-necessity and treatment-protocol determinations should be reviewed using applicable reproductive-medicine standards and guidelines.

Defined Terms

Infertility

ConditionThe condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy.

Applicable timeframeDuring a one-year period.

Religious employer

Qualified church-controlled organizationAn organization that is a qualified church-controlled organization as defined in 26 USC 3121.

Church-affiliated organizationA church-affiliated organization.

Policy Summary

PayerConnecticut Insurance Department

PolicyInfertility Treatment and Procedures Coverage

Policy CodePolicy HC-64

Change TypeModified

Effective DateJanuary 20, 2006

Next Review DateN/A

Key ActionBefore covering IVF, GIFT, ZIFT, or low tubal ovum transfer, confirm that less expensive and medically viable covered infertility treatment has been unsuccessful.

SourceLink

On This Page

Facility conformity with ASRM or SREI standards and guidelines

The bulletin recommends using these standards when reviewing medical protocols and medical necessity.

Combined lifetime maximum

2 cycles combined for IVF, GIFT, ZIFT, and low tubal ovum transfer.

Embryo implantation limitNo more than 2 embryo implantations per cycle.

Cycle countingEach fertilization or transfer is credited toward the maximum as 1 cycle.

Infertility drug copay

Allowable copay range$0-$40.

Infertility drug coinsurance

Allowable coinsurance range0%-50%.

For individual policies, obtain the Insurance Commissioner-prescribed disclosure of prior infertility treatment or procedures for which the individual received coverage under another health insurance policy. Capture treatment or drug therapy, dates, providers, and the applicable prior carrier; do not apply this disclosure requirement to group policies where HIPAA prohibits prior benefits from being applied to current lifetime maximums.

Use the prescribed Connecticut disclosure form and manner.
Confirm whether prior coverage was individual, fully insured group, or self-insured.

Documentation Required

Secure Attestation and Record Authorization

Obtain the individual's signed attestation that the submitted information is true and accurate, together with authorization to release medical records needed to verify previous infertility treatment and procedures. The authorization may cover prior insurers and relevant providers and must be used solely to determine treatment applied toward the statutory maximums.

Retain the signed date and attestation.
Retain authorization to obtain and review relevant medical records.

Billing Rule

Exclude Non-Countable Treatment

Do not count qualifying treatment toward the statutory limits when no insurance claim was made, submitted, or paid, including treatment paid out-of-pocket, services reimbursed under self-funded plans, or services for which the individual received no insurance benefits.

Exclude unreimbursed cash-paid treatment.
Exclude services reimbursed under self-funded plans.
Document the basis for excluding treatment from the lifetime count.

Denial Risk

Apply the Age Limit

Apply the age limitation strictly: mandated infertility coverage may be limited to expenses incurred before the individual's fortieth birthday. Deny mandate coverage for expenses incurred after that date, even when the individual is in the middle of a treatment cycle.

Use the date of service or expense incurred—not treatment-cycle completion—to apply the limit.
The limitation applies at the individual's fortieth birthday.

Billing Rule

Track Lifetime Cycle Maximums

Track lifetime cycle maximums across the individual's lifetime, subject to applicable group-plan HIPAA restrictions on applying prior-plan benefits. Ovulation induction is limited to four cycles; intrauterine insemination to three cycles; and IVF, GIFT, ZIFT, and low tubal ovum transfer are combined into a maximum of two cycles, with no more than two embryo implantations per cycle.

Ovulation induction: maximum four lifetime cycles.
Intrauterine insemination: maximum three lifetime cycles.
IVF/GIFT/ZIFT/low tubal ovum transfer: maximum two combined lifetime cycles; each fertilization or transfer counts as one cycle.

Step Therapy

Enforce the Required Treatment Pathway

Before covering IVF, GIFT, ZIFT, or low tubal ovum transfer, verify and document the required prior failure to conceive, produce conception, or sustain a successful pregnancy through less expensive and medically viable covered infertility treatment or procedures.

Apply the prerequisite to each advanced procedure category.
Confirm that the prerequisite treatment was medically viable and covered under the policy.

Denial Risk

Verify Facility Standards

Confirm that covered infertility treatment and procedures are performed at facilities conforming to standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility.

Validate facility compliance before authorization or payment.
Review treatment protocols and medical necessity in light of the same professional standards and guidelines.

Denial Risk

Exclude Non-Covered Services

Identify services that are not mandated infertility coverage and exclude them from the benefit: donor costs, expenses related to pregnancies and deliveries resulting from infertility treatment, reversal of surgical sterilization, and gestational-carrier or surrogate-parenting arrangements.

Donor costs.
Pregnancy and delivery expenses resulting from treatment.
Reversal of male or female surgical sterilization.
Gestational-carrier or surrogate-parenting arrangements.

Documentation Required

Process Religious Exclusions

Process a written statement from an individual or religious employer asserting that infertility diagnosis or treatment methods conflict with bona fide religious beliefs. A policy or rider may exclude those methods, but the policy, application, and sales brochure must provide written notice of the exclusion in at least ten-point type.

Obtain and retain the written religious-belief request.
Confirm that exclusion language and notice meet the required format and placement.