CurrentFidelis CarePolicy N/A

infertility_coverage_details

Defines Fidelis Care coverage of certain infertility medications and associated services (office visits, HSG x-rays, pelvic ultrasounds, blood tests) for Medicaid Managed Care members beginning October 1, 2019, limited to 3 lifetime treatment cycles and subject to age-based eligibility/time-trying thresholds.

Policy Summary

PayerFidelis Care

Policyinfertility_coverage_details

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2019

Next Review Date

Key ActionProvider must document member age and duration of regular, unprotected intercourse (12 months for ages 21-34; 6 months for ages 35-44) to support eligibility for covered infertility services.

SourceLink

POLICY UPDATE CHANGES

No material changes — brief indicates coverage established October 1, 2019 and has no listed changes.

3Lifetime treatment cycles allowed

21-34 / 35-44Covered member ages

12m / 6mRequired duration by age group

Coverage Summary

Defines Fidelis Care coverage of certain infertility medications and associated services (office visits, HSG x-rays, pelvic ultrasounds, blood tests) for Medicaid Managed Care members beginning October 1, 2019. Coverage includes prescribing and monitoring of infertility medications and related diagnostic and monitoring services, and is limited to 3 cycles of treatment per lifetime. Eligibility is age-based with specific duration-of-unprotected-sex thresholds for approval.

Eligibility and Covered Services

Eligibility based on age and duration of unprotected intercourse

Members are eligible when ALL of the following age-specific conditions are met:

ONE of

Age 21-34 criteria
- Member age is between 21 and 34 years inclusive
- Member has been unable to become pregnant after 12 months of regular, unprotected sex12 months
Age 35-44 criteria
- Member age is between 35 and 44 years inclusive
- Member has been unable to become pregnant after 6 months of regular, unprotected sex6 months

Provider Requirements and Operational Notes

Documentation Required

Document duration of infertility attempts and age

Document the member's age and the duration of regular, unprotected intercourse in the medical record to support eligibility. Use 12 months as the threshold for members aged 21–34 and 6 months as the threshold for members aged 35–44.

Prior Authorization

Lifetime cycle limit applies

There is a 3-cycle lifetime limit on infertility treatment coverage. Providers should account for this limit when planning treatment; prior authorization may be required per plan processes—contact Member Services for authorization and plan-specific requirements.

Definitions and Background

Fidelis Care began covering services to help Medicaid Managed Care members become pregnant starting October 1, 2019. Coverage applies to certain infertility medications and associated diagnostic and monitoring services, including office visits, x-rays of the uterus and fallopian tubes, pelvic ultrasounds, and blood tests; treatment is limited to 3 cycles of treatment per lifetime and subject to age-based eligibility criteria.

Cycle: Not explicitly defined in the document; used to denote a course of infertility treatment (limited to 3 per lifetime).