Large Group Health Plans Must Cover IVF & Fertility Services Starting July 1, 2025

Legal Update

Brought to you by: Hammett Health, Inc.

On Sept. 29, 2024, Gov. Gavin Newsom signed Senate Bill (SB) 729, which will require large group health care service plans to cover infertility and fertility services, including in vitro fertilization (IVF), beginning July 1, 2025.

Highlights

Key changes made by SB 729 include the following. The law:

Revises the definition of infertility and removes the exclusion of IVF from coverage;
Requires coverage for a maximum of three completed oocyte retrievals;
Eliminates a requirement that a health plan provide infertility treatment under agreed-upon terms that are communicated to all group contract holders and policyholders; and
Prohibits a health plan from placing different conditions or coverage limitations on fertility medications or services than those that would apply to other conditions.

Definition of Infertility

For purposes of the coverage mandate, “infertility” means a condition or status characterized by any of the following:

A licensed physician’s findings, based on a patient’s medical, sexual and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.
A person’s inability to reproduce either as an individual or with their partner without medical intervention.
The failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. This means no more than 12 months of unprotected sexual intercourse for a person under 35 years of age or no more than six months of unprotected sexual intercourse for a person 35 years of age or older. Pregnancy resulting in miscarriage does not restart the 12-month or six-month time period to qualify as having infertility. The definition cannot prevent testing and diagnosis of infertility before the 12-month or six-month period to establish infertility.

Provided to you by Hammett Health, Inc.

Covered Health Care Plans

Large group health care service plans are generally those that cover over 100 people.
While small group plans will not be required to cover such services, they will be required to offer such coverage beginning July 1, 2025.
The coverage mandate does not apply to plans sponsored by religious employers, or to Medi-Cal managed health care service plans.

Large group health plans will be required to cover infertility and fertility services, including IVF, beginning July 1, 2025.

This Legal Update is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. ©2024 Zywave, Inc. All rights reserved.