Medicaid Coverage for Infertility Treatments and Fertility Preservation
The information below outlines Medicaid coverage for infertility treatments and fertility preservation services across various states in the U.S.
Medicaid Coverage for Infertility Treatments:
Medicaid benefits include 3 cycles of ovulation-enhancing drugs and monitoring, as detailed below:
https://www.health.ny.gov/health_care/medicaid/program/update/2019/2019-06.htm#ovulation
“Effective October 1, 2019, Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) benefits will include medically necessary ovulation enhancing drugs and medical services related to prescribing and monitoring the use of such drugs for individuals 21 through 44 years of age experiencing infertility.”
“This applies to MMC plans, including mainstream MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs). FFS and MMC infertility benefits include office visits, hysterosalpingograms, pelvic ultrasounds, blood testing, and ovulation enhancing drugs included in the Medicaid formulary.”
“The ovulation enhancing drugs included in the Medicaid formulary are bromocriptine, clomiphene citrate, letrozole, and tamoxifen. FFS and MMC infertility benefits will be limited to coverage for three (3) cycles of treatment per lifetime. For Medicaid purposes, infertility is a condition characterized by the incapacity to conceive, defined by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse for individuals 21 through 34 years of age, or after six months for individuals 35 through 44 years of age.”
House Bill 214, "Insurance Coverage Modifications," specified a state plan amendment for Medicaid coverage for IVF and genetic testing for carriers of 5 genetic diseases, and went into effect on 5/1/2024:
“This amendment seeks approval to allow the State to provide in vitro fertilization services and genetic testing for Medicaid eligible individuals who have one of the following conditions: Cystic fibrosis, spinal muscular atrophy, Morquio syndrome, myotonic dystrophy, or sickle cell anemia.”
D.C. Law 25-49, “Expanding Access to Fertility Treatment Amendment Act of 2023,” specified a state plan amendment for Medicaid coverage for infertility diagnosis and 3 cycles of ovulation-enhancing drugs and monitoring, as detailed below. This amendment was approved and coverage was effective 1/1/2024.
https://lims.dccouncil.gov/downloads/LIMS/52068/Signed_Act/B25-0034-Signed_Act.pdf?Id=166812
“By January 1, 2024, the Department of Health Care Finance shall submit an amendment to the Medicaid state plan to the Centers for Medicare & Medicaid Services to authorize coverage through Medicaid for the diagnosis of infertility and any medically necessary ovulation enhancing drugs and medical services related to prescribing and monitoring the use of such drugs, which shall include at least 3 cycles of ovulation-enhancing medication treatment over an enrollee’s lifetime.”
Medicaid Coverage for Fertility Preservation:
Public Act 100-1102 required Medicaid coverage for standard fertility preservation services, effective 1/1/2019, as detailed below:
“Public Act 100-1102 requires the Department to cover medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectlycause iatrogenic infertility. Medically necessary fertility preservation services will be covered for participants ages 14 through 45 and will be limited to office visits, pelvic ultrasounds, sperm and oocyte cryopreservation and storage, medications/injectables and laboratory testing.”
Maryland Law H.B. 908, “Coverage of Fertility Preservation Procedures for Iatrogenic Infertility,” requires the Maryland Medical Assistance Program to cover fertility preservation services for iatrogenic infertility, effective October 7, 2023, as detailed below:
“Effective October 7, 2023, the Maryland Medical Assistance Program (the Program) will provide coverage of fertility preservation services for iatrogenic infertility, as required by House Bill (HB) 908–Coverage of Fertility Preservation Procedures for Iatrogenic Infertility –(Ch. 715 of the Acts of 2018). Iatrogenic infertility includes impairment of fertility by surgery, radiation, chemotherapy, gender-affirming treatments, or other medical treatment or intervention affecting reproductive organs or processes.”
SB 516, An Act Generally Revising Laws Related to Fertility Preservation Services for People Diagnosed with Cancer,” required Medicaid coverage for fertility preservation services for cancer patients at risk of iatrogenic infertility, effective January 1, 2024, as detailed below:
https://leg.mt.gov/bills/2023/billpdf/SB0516.pdf
“Medical assistance provided by the Montana program includes the following services:
… (p) fertility preservation services in accordance with [section 3].”
“Section 3. Coverage of fertility preservation services. (1) Each individual and group disability policy, certificate of insurance, and membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state that provides coverage for hospital, medical, or surgical services must cover medically necessary costs for standard fertility preservation services when an insured member is diagnosed with cancer and the standard of care involves medical treatment that may directly or indirectly cause iatrogenic infertility.”
Oklahoma Law S.B. 1334, “Corinne’s Law,” requires coverage of standard fertility preservation services for all health benefit plans, including Medicaid, effective January 1, 2025, as detailed below:
http://www.oklegislature.gov/BillInfo.aspx?Bill=SB1334&Session=2400
“Any health benefit plan, including the Oklahoma Employees Insurance Plan, that is offered, issued, or renewed on and after the effective date of this act shall provide coverage for standard fertility preservation services, only for individuals diagnosed with cancer and who are within reproductive age, when a medically necessary treatment may directly or indirectly cause iatrogenic infertility.”
HB 192, “Fertility Treatment Amendments,” specified a Medicaid waiver for fertility preservation services for cancer patients, as detailed below. The waivers went into effect on 5/1/2024:
“Before January 1, 2022, the department shall apply for a Medicaid waiver or a state plan amendment with CMS to implement the coverage described in Subsection (3). If the waiver or state plan amendment described in Subsection (2) is approved, the Medicaid program shall provide coverage to a qualified enrollee for standard fertility preservation services.”
The following waiver amendment was submitted on 12/27/21:
“This amendment seeks approval to allow the State to expand Medicaid coverage for fertility preservation for individuals diagnosed with cancer.”