The California Department of Managed Health Care (DMHC), which regulates health care plans covering 26 million California patients, confirmed that fertility preservation prior to medical treatment which could directly or indirectly cause infertility is a covered health benefit under the overarching language of the Knox-Keene Health Care Service Plan Act of 1975. This decades old statute provides for the coverage of any “medically necessary” medical care. As in all instances, for all types of care, the patient must meet the medical guidelines for care to be covered.
Beginning in 2011, multiple legislative proposals to require coverage for fertility preservation were introduced in the state. These bills were viewed as new mandates, because fertility preservation guidelines did not establish these services as standard medical care. Because of implementation of the Affordable Care Act at the time of the previous bills, if this was a new coverage mandate, the state could have been financially responsible for adding this additional benefit. The Governor vetoed previous bills, not wanting to incur additional state costs.
In the meantime, however, practice guidelines have evolved and fertility preservation is now recognized as standard care. This has been confirmed by patient cases where coverage initially was denied by health plans, and appeals were subsequently submitted to the DMHC’ s Independent Medical Review (IMR) process. Those resulting IMRs found fertility preservation to be medically necessary in those cases, and the coverage denials were overturned and coverage was obtained. Now that coverage is confirmed under existing law, no additional legislation is necessary at this time.
This coverage only applies to California health plans regulated by the DMHC, which covers 96% of persons covered by commercial insurance, or 2/3 of California residents. As the majority of Medi-Cal recipients are in managed care plans, this coverage should apply to those patients as well. The law does not apply to out-of-state plans, worker’s compensation, self-funded ERISA plans, Veterans’ Administration, traditional fee-for-service Medi-Cal or Medicare. There still may be coverage under those plans should the plan elect to provide coverage, or if other laws apply.
While this coverage does not apply to out-of-state plans, patients could explore whether that state has similar laws about medically necessary coverage, and whether that state regulator has an appeals process similar to California’s Independent Medical Review process. They still may be able to get coverage, just not under the California law.
RPMG provides fertility preservation procedures, predominantly egg and embryo freezing. For more information please see our page on Egg Freezing.