New Jersey IVF Coverage Mandate
Infertility is defined as the failure to conceive after one year of unprotected sexual intercourse.
In the United States approximately 15-20 percent of married couples will experience some degree of infertility. This means that 1 in 6 couples will need professional assistance. Traditionally, human infertility has been referred to as the “woman’s problem,” ignoring the male contribution. More recent studies have revealed that in a population of infertile couples, about 40 percent of infertility cases are due to male factors, 40 percent are due to female factors and the other 20 percent are due to female and male factors together.
But a diagnosis of infertility does not mean that becoming pregnant is impossible. Nearly 90 percent of infertility cases are treatable with medical therapies ranging from drug treatment and surgery to advanced reproductive technologies such as in vitro fertilization (IVF).
To completely evaluate the reproductive potential of a couple, the physician must see the couple together to facilitate treatment. Infertility can be a multi-factor problem, where several conditions when presented alone are not so important but when added together could markedly influence the reproductive potential of a couple. Therefore, a systematic, simultaneous basic evaluation should be implemented on both spouses.
New Jersey mandate for infertility coverage
Currently only 16 states in the U.S. – including New Jersey – have laws requiring health insurance companies to provide coverage for infertility treatment. The insurance mandate states that any insurance provider who provides pregnancy-related benefits must also cover infertility treatment and IVF costs. The law also requires health plans contracting to cover state employees and teachers to include the same infertility coverage.
A recent update to the mandate defines infertility as “a disease or condition that results in the abnormal function of the reproductive system.” The new law aligns its requirements with the medical definition of infertility, and allows women with same sex partners and women without partners to qualify for infertility coverage.
If you meet the following criteria and definition of infertility, you may be able to receive health insurance coverage for infertility treatment in the state of New Jersey:
- A male who is unable to impregnate a female
- A female with a male partner and under 35 years of age who is unable to conceive after 12 months of unprotected sexual intercourse.
- A female with a male partner and 35 years of age or over who is unable to conceive after six months of unprotected sexual intercourse.
- A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision.
- A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision.
- Partners who are unable to conceive as a result of involuntary medical sterility.
- A person who is unable to carry a pregnancy to live birth.
- A previous determination of infertility pursuant to the law.
The New Jersey infertility insurance mandate (officially known as the New Jersey Family Building Act) will cover the costs of the following treatments for eligible patients at a facility that conforms with ACOG and ASRM guidelines:
- In vitro fertilization (IVF), including fresh and frozen embryo transfers, with four completed egg retrievals per lifetime
- IVF using donor eggs, and IVF where the embryo is transferred to a gestational carrier (surrogate)
- Intracytoplasmic sperm injection (ICSI)
- Artificial insemination
- Assisted hatching
- Fertility medications
- Fertility surgery
- Gamete intrafallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
- Fertility testing and diagnostics
- Ovulation induction.