Infertility Coverage Expansion for HIP Medicaid and Commercial Members

Date: October 25, 2019

Based on changes to New York State law, EmblemHealth will be enhancing infertility benefits for its Medicaid and commercial members as follows:

Medicaid Expansion of Coverage for Ovulation Enhancing Drugs and Related Medical Services

As of Oct. 1, 2019, EmblemHealth will cover medically necessary ovulation enhancing drugs and medical services related to prescribing and monitoring the use of such drugs. This applies to Medicaid members, ages 21 through 44, who are experiencing infertility. 

The following ovulation enhancing drugs will be covered for a limit of three cycles of treatment per lifetime:

  • bromocriptine
  • clomiphene citrate
  • letrozole
  • tamoxifen

EmblemHealth will also cover services related to prescribing and monitoring the use of such drugs. The infertility benefit includes:

  • Office visits
  • X-ray of the uterus and fallopian tubes
  • Pelvic ultrasound
  • Blood testing

Medicaid members may be eligible for infertility services if they meet the following criteria:

  • 21-34 years old and are unable to get pregnant after 12 months of regular, unprotected sex.
  • 35-44 years old and are unable to get pregnant after 6 months of regular, unprotected sex.

For more information visit the New York State Department of Health website.

Essential Plan, Individual On/Off Exchange, and Small Group Expansion of Coverage for Fertility Preservation Services

Effective Jan. 1, 2020, EmblemHealth will cover standard fertility preservation services when a medical treatment will directly or indirectly lead to iatrogenic infertility.

  • "Iatrogenic infertility” is defined as an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

Standard fertility preservation services include the collection, preservation, and storage of ova and sperm.

EmblemHealth will continue to cover services for the diagnosis and treatment (surgical and medical) of infertility. This includes basic infertility services. Comprehensive Infertility services and Advanced Infertility services are covered when Basic Infertility services do not result in increased fertility. Standard limitations and exclusions apply.

For more information, refer to 2020 Schedule of Benefits and Member Contracts. 

Large Group Expansion of IVF Coverage

For new large groups effective on or after Jan. 1, 2020, and for existing groups upon their 2020 renewal, EmblemHealth will cover three cycles of in-vitro fertilization (IVF) treatments per lifetime for infertility.

  • "Infertility” is defined as 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 12 months of regular, unprotected sexual intercourse or therapeutic donor insemination. Or, if a woman is 35 years old or older: after six months of regular, unprotected sexual intercourse or therapeutic donor insemination.
  • "Cycle” is defined as either all treatment that starts when:
    • Preparatory medications are administered for ovarian stimulation for oocyte retrieval with the intent of undergoing in-vitro fertilization using a fresh embryo transfer; or
    • Medications are administered for endometrial preparation with the intent of undergoing in-vitro fertilization using a frozen embryo transfer.

Additionally, EmblemHealth will also cover standard fertility preservation services when a medical treatment may directly or indirectly cause iatrogenic infertility.

  • "Iatrogenic infertility” is defined as an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

Cost-sharing may apply. Please refer to the specific Benefit Set/Product ID.