02-031 C.M.R. ch. 865, § 4 - Coverage Requirements

1. In making coverage available under this rule, a carrier shall not discriminate against any class of enrollees protected by the Maine Human Rights Act, Title 5 M.R.S. Chapter 337. In particular, carriers shall make coverage available regardless of sexual orientation, gender identity or expression, and family composition, including single parents.

2. A carrier shall adopt and use guidelines no less favorable than those established and adopted by a standard-setting organization, including without limitation guidelines for:

(A) identifying experimental fertility procedures and treatments not covered for the diagnosis and treatment of infertility or for fertility preservation;

(B) identifying the required training, experience, and other standards for health care providers to provide fertility diagnostic care, fertility treatment, and fertility preservation services; and

(C) determining appropriate candidates for fertility care, including without limitation:

(1) enrollees with a medical need for fertility preservation services, including patients who expect to undergo treatment, as designated in the guidelines, that may directly or indirectly cause a risk of iatrogenic infertility, and

(2) enrollees who have been diagnosed by a physician as having a genetic trait associated with certain conditions that include, at a minimum, all those specified by the standard-setting organization designated by the carrier.

3. A carrier shall not impose a separate visit maximum or procedure maximum on any fertility treatment, except as expressly permitted in Section 6. A carrier shall not require a separate deductible for fertility coverage or any other separate cost sharing requirement except as permitted by Paragraph A of this subsection.

(A) A plan's medical coverage may not establish higher copayments for fertility coverage than for other comparable specialty services. After the deductible is satisfied, the enrollee's coinsurance may not exceed the greater of 20%, or the percentage specified in the plan for other comparable specialty services.

(B) A plan's prescription drug coverage may not establish less favorable terms for fertility drugs than for other comparable medications, including the assignment of fertility drugs to cost-sharing tiers.

(C) A carrier shall comply with any other restrictions on cost sharing required by applicable law.

4. A carrier shall not impose any preauthorization requirements or other utilization management requirements on fertility treatment other than requirements of general applicability that do not have the purpose or effect of defeating the purposes of this subsection. For example, if a carrier requires all hospitalizations or all surgeries to be preauthorized, and a particular fertility treatment involves a hospitalization or a surgical procedure, the carrier may require preauthorization of that hospitalization or surgical procedure.

5. A carrier may limit benefits required by this rule to services performed at facilities that conform to standards established by the carrier's designated standard-setting organization. A carrier shall not impose on facilities or other providers any additional standards in the policy or contract or in the certificate or evidence of coverage applicable to fertility services.

Notes

02-031 C.M.R. ch. 865, § 4