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.

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.

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.