02-031 C.M.R. ch. 865, § 6 - Permissible Benefit Limitations and Exclusions

1. Benefits for intrauterine or vaginal insemination may be limited to three lifetime cycles.

2. Benefits for egg retrieval may be subject to a lifetime limit of four completed egg retrievals.

3. Benefits for any combination of gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), or fresh or frozen embryo transfer (FET) may be limited to two lifetime cycles.

4. In calculating any lifetime limit permitted by this rule, procedures where the cost was not covered by any carrier, self-insured health plan, or governmental program shall not count toward the limit, and a covered procedure shall only be counted against the lifetime limit for the individual fertility patient who filed the claim.

5. This rule does not prohibit coverage exclusions for the following services:

(A) Reversal of voluntary sterilization;

(B) Nonmedical costs of an egg or sperm donor, gestational carrier, or surrogate;

(C) Maternity care and prenatal care services, or services to treat complications of pregnancy or childbirth, rendered to a gestational carrier or surrogate who is not covered by the carrier's policy or contract;

(D) Experimental fertility procedures;

(E) Ovulation kits and sperm testing kits and supplies designed for home use;

(F) In vitro fertilization, gamete intrafallopian tube transfer, and zygote intrafallopian tube transfer for persons who have not used all reasonable less expensive and medically appropriate treatments for infertility;

(G) In vitro fertilization or gamete intrafallopian tube transfer involving eggs that were collected from a fertility patient who had exceeded the limit of four covered completed egg retrievals; and

(H) In vitro fertilization when the resulting embryos are to be transferred to a fertility patient who has exceeded the limit of two covered embryo transfer cycles.

6. Any other limitations or exclusions on fertility coverage must be consistent with the carrier's clinical guidelines, which must comply with the requirements of this rule. The carrier shall adopt and maintain its clinical guidelines in writing, citing with specificity any data or scientific reference relied upon, and make them available to any enrollee upon request.

Notes

02-031 C.M.R. ch. 865, § 6