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.