HF4609

Purpose

• The bill would require health plans that provide maternity benefits to Minnesota residents to cover infertility diagnosis and treatment along with standard fertility preservation services. It would apply to related programs like MinnesotaCare and set up a state reimbursement process to offset some of the added costs for plans. It also adds specific definitions and guidelines to govern these new requirements and limits, funding, and reporting.

Key terms and definitions

• Infertility: a disease/status defined as the inability to establish a pregnancy or carry a pregnancy to live birth after a specified period of unprotected sex (12 months if under 35; 6 months if 35 or older), or based on a clinician’s determination after review of medical history and tests.
• Diagnosis of and treatment for infertility: medical procedures and medications used to diagnose or treat infertility, aligned with established guidelines.
• Standard fertility preservation services: procedures aligned with guidelines from major medical organizations for people who have a medical condition or who are expected to undergo treatments (e.g., medication, surgery, radiation, chemotherapy) that may impair fertility.
• Embryo transfers: the bill requires coverage for unlimited embryo transfers, with a possible limit of four completed oocyte retrievals.
• Oocyte retrievals: a limit of up to four completed procedures (with single embryo transfer prioritized when medically appropriate).
• Maternity benefits: the plan category to which these infertility coverages must apply.

Scope and Coverage requirements

• Applies to all health plans that provide maternity benefits to Minnesota residents.
• Requires comprehensive coverage for:
  • Diagnosis of infertility
  • Treatment for infertility
  • Standard fertility preservation services
• Reproductive procedures and preservation must follow established medical practices and guidelines (ACOG, ASRM, and ASCO).

Main Provisions and what the bill seeks to accomplish

• Coverage must be comprehensive for infertility diagnosis and treatment and standard fertility preservation services.
• Unlimited embryo transfers are covered, but there may be a limit of four completed oocyte retrievals.
• Single embryo transfer must be used when medically appropriate and recommended by the treating provider.
• Coverage for surgical reversal of elective sterilization is not required.
• Cost-sharing (copays, deductibles, coinsurance) for infertility coverage cannot exceed the cost-sharing structures used for maternity coverage.
• No general exclusions or limitations unique to fertility services beyond those that apply to maternity coverage, including no special limits on fertility medications or restrictions based on third-party fertility services.
• These protections apply in addition to existing maternity coverage, and the bill integrates fertility care into health insurance requirements.

Cost-sharing and exclusions

• Health plans may not impose higher cost-sharing for infertility coverage than for maternity coverage.
• Exclusions, waiting periods, utilization review, referral requirements, or other limitations that would not be generally applicable to maternity coverage are prohibited, with limited exceptions outlined in the bill.
• The bill prohibits limitations based on participation in fertility services provided through third parties.

Reimbursement and funding

• The commissioner of commerce must reimburse health plan companies for the incremental costs of providing this new coverage.
• Reimbursement is limited to coverage that would not have been provided by the plan without these new requirements.
• Plans’ treatments and services already covered as of January 1, 2026 are ineligible for reimbursement under this provision.
• Plans must report quantified costs attributable to the additional benefit to the commissioner, using a format developed by the commissioner.
• The commissioner will evaluate submissions and make payments under relevant federal rules (45 C.F.R. 155.170).
• Beginning in fiscal year 2028, an appropriation from the general fund to the commissioner of commerce will cover the payments needed to defray the cost of providing this coverage, including administrative costs.

Implementation timing and related funding

• The reimbursement program is funded by annual appropriations beginning in FY 2028.
• The legislation also requires linking to Minnesota Statutes governing health coverage and MinnesotaCare, with coding and implementation specifics to be added to existing law.

Significant changes to existing law

• Adds mandatory coverage for infertility diagnosis, treatment, and standard fertility preservation services to health plans that provide maternity benefits.
• Introduces a reimbursement mechanism to offset incremental costs for plans, funded by the state beginning in FY 2028.
• Incorporates guidelines from major medical organizations (ACOG, ASRM, ASCO) into definitions and standards for infertility care and fertility preservation.
• Establishes a framework for cost-sharing parity with maternity benefits and prohibits plan-specific exclusions or limitations that would uniquely restrict fertility services.
• Expands coverage obligations to MinnesotaCare and similar programs by linking infertility coverage and related services to state health coverage provisions.

Relevant Terms infertility, diagnosis of infertility, treatment for infertility, standard fertility preservation services, ASRM, American Society for Reproductive Medicine, ASCO, American Society of Clinical Oncology, ACOG, single embryo transfer, unlimited embryo transfers, oocyte retrievals, fertility medications, maternity coverage, deductible, copayment, coinsurance, cost-sharing, health plan, MinnesotaCare, commissioner of commerce, reimbursement, general fund, appropriation, excluded treatments, live birth, fertility services, elective sterilization reversal, medical guidelines.