Report Title:

Insurance; covered procedures; infertility

Description:

Requires health insurers to provide coverage for medically necessary expenses incurred in the diagnosis and treatment of infertility.

HOUSE OF REPRESENTATIVES

H.B. NO.

2821

TWENTY-SECOND LEGISLATURE, 2004

 

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

relating to insurance.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. Section 431:10A-116.5, Hawaii Revised Statutes, is amended to read as follows:

"§431:10A-116.5 In vitro fertilization procedure coverage. (a) All individual and group accident and health or sickness insurance policies which provide pregnancy-related benefits shall include in addition to any other benefits for treating infertility, [a one-time only benefit for all outpatient expenses arising from in vitro fertilization procedures performed on the insured or the insured's dependent spouse; provided that:

(1) Benefits under this section shall be provided to the same extent as the benefits provided for other pregnancy-related benefits;

(2) The patient is the insured or covered dependent of the insured;

(3) The patient's oocytes are fertilized with the patient's spouse's sperm;

(4) The:

(A) Patient and the patient's spouse have a history of infertility of at least five years' duration; or

(B) Infertility is associated with one or more of the following medical conditions:

(i) Endometriosis;

(ii) Exposure in utero to diethylstilbestrol, commonly known as DES;

(iii) Blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or

(iv) Abnormal male factors contributing to the infertility;

(5) The patient has been unable to attain a successful pregnancy through other applicable infertility treatments for which coverage is available under the insurance contract; and

(6) The in vitro fertilization procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Society for Reproductive Medicine minimal standards for programs of in vitro fertilization.] benefits for medically necessary expenses incurred in the diagnosis and treatment of infertility performed on the insured or the insured's dependent spouse; provided that:

(1) Benefits under this section shall be provided to the same extent as the benefits provided for other pregnancy-related benefits;

(2) The same co-payments, deductibles, and benefit limits that apply to other pregnancy-related benefits shall apply to benefits under this section;

(3) Benefits under this section shall include but not be limited to:

(A) Diagnostic testing and diagnosis;

(B) Medications;

(C) Surgery;

(D) In vitro fertilization;

(E) Embryo transfer;

(F) Artificial insemination;

(G) Intracytoplasmic sperm injection; and

(H) Three completed egg retrievals per lifetime.

and

(4) In vitro benefits:

(A) Shall be provided if:

(i) The patient is the insured or covered dependent of the insured;

(ii) The patient's oocytes are fertilized with the patient's spouse's sperm; and

(iii) The procedure is performed at facilities that conform to minimal standards established by the American College of Obstetricians and Gynecologists or the American Society for Reproductive Medicine; and

(B) May be limited to a covered person who:

(i) has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy;

(ii) Has not reached the limit of three completed egg retrievals; and

(iii) Is forty-five years of age or younger.

(b) For the purposes of this section[, the term "spouse" means a person who is lawfully married to the patient under the laws of the State.]:

"Infertility" means a disease or condition affecting an individual that results in the abnormal function of the reproductive system such that the person is:

(1) Considered medically sterile; or

(2) Unable to:

(A) Impregnate another person;

(B) Conceive after one year of unprotected intercourse if the female partner is under the age of thirty-five;

(C) Conceive after six months of unprotected intercourse if the female partner is thirty-five years or older; or

(D) Carry a pregnancy to live birth.

"Spouse" means a person who is lawfully married to the patient under the laws of the State.

(c) The requirements of this section shall apply to all new policies delivered or issued for delivery in this State after June 26, 1987."

SECTION 2. Section 432:1-604, Hawaii Revised Statutes, is amended to read as follows:

"§432:1-604 In vitro fertilization procedure coverage. (a) All individual and group hospital or medical service plan contracts which provide pregnancy-related benefits shall include in addition to any other benefits for treating infertility, [a one-time only benefit for all outpatient expenses arising from in vitro fertilization procedures performed on the subscriber or member or the subscriber's or member's dependent spouse; provided that:

(1) Benefits under this section shall be provided to the same extent as the benefits provided for other pregnancy-related benefits;

(2) The patient is a subscriber or member or covered dependent of the subscriber or member;

(3) The patient's oocytes are fertilized with the patient's spouse's sperm;

(4) The:

(A) Patient and the patient's spouse have a history of infertility of at least five years' duration; or

(B) Infertility is associated with one or more of the following medical conditions:

(i) Endometriosis;

(ii) Exposure in utero to diethylstilbestrol, commonly known as DES;

(iii) Blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or

(iv) Abnormal male factors contributing to the infertility;

(5) The patient has been unable to attain a successful pregnancy through other applicable infertility treatments for which coverage is available under the contract; and

(6) The in vitro fertilization procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Society for Reproductive Medicine minimal standards for programs of in vitro fertilization.] benefits for medically necessary expenses incurred in the diagnosis and treatment of infertility performed on the subscriber or member, or the subscriber's or member's dependent spouse; provided that:

(1) Benefits under this section shall be provided to the same extent as the benefits provided for other pregnancy-related benefits;

(2) The same co-payments, deductibles, and benefit limits that apply to other pregnancy-related benefits shall apply to benefits under this section;

(3) Benefits under this section shall include but not be limited to:

(A) Diagnostic testing and diagnosis;

(B) Medications;

(C) Surgery;

(D) In vitro fertilization;

(E) Embryo transfer;

(F) Artificial insemination;

(G) Intracytoplasmic sperm injection; and

(H) Three completed egg retrievals per lifetime.

and

(4) In vitro benefits:

(A) Shall be provided if:

(i) The patient is the insured or covered dependent of the insured;

(ii) The patient's oocytes are fertilized with the patient's spouse's sperm; and

(iii) The procedure is performed at facilities that conform to minimal standards established by the American College of Obstetricians and Gynecologists or the American Society for Reproductive Medicine; and

(B) May be limited to a covered person who:

(i) has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy;

(ii) Has not reached the limit of three completed egg retrievals; and

(iii) Is forty-five years of age or younger.

(b) For the purposes of this section[, the term "spouse" means a person who is lawfully married to the patient under the laws of the State.]:

"Infertility" means a disease or condition affecting an individual that results in the abnormal function of the reproductive system such that the person is:

(1) Considered medically sterile; or

(2) Unable to:

(A) Impregnate another person;

(B) Conceive after one year of unprotected intercourse if the female partner is under the age of thirty-five;

(C) Conceive after six months of unprotected intercourse if the female partner is thirty-five years or older; or

(D) Carry a pregnancy to live birth.

"Spouse" means a person who is lawfully married to the patient under the laws of the State.

(c) The requirements of this section shall apply to all hospital or medical service plan contracts delivered or issued for delivery in this State after June 26, 1987."

SECTION 3. Section 432D-23, Hawaii Revised Statutes, is amended to read as follows:

"§432D-23 Required provisions and benefits. Notwithstanding any provision of law to the contrary, each policy, contract, plan, or agreement issued in the State after January 1, 1995, by health maintenance organizations pursuant to this chapter, shall include benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116, 431:10A-116.5, 431:10A-116.6, 431:10A - , 431:10A-119, 431:10A-120, and 431:10A-121, and chapter 431M."

SECTION 4. New statutory material is underscored.

SECTION 5. This Act shall take effect upon its approval.

INTRODUCED BY:

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