“To amend the Patient Protection and Affordable Care Act to include fertility treatment and care as an essential health benefit.”
No CRS summary available for this bill.
This section includes fertility treatment and care as an essential health benefit (EHB) under the Patient Protection and Affordable Care Act (ACA) by adding it as a new mandatory category (K) in the list of 11 general benefit categories that non-grandfathered plans in the individual and small group markets must cover. (As background, EHBs set minimum coverage standards for ACA Marketplace plans and related coverage to ensure comprehensive benefits benchmarked to typical employer plans.) It further defines fertility treatment and care to include (1) preservation of oocytes, sperm, or embryos; (2) artificial insemination; (3) assisted reproductive technology such as in vitro fertilization with at least three complete oocyte retrievals and unlimited embryo transfers per the American Society for Reproductive Medicine guidelines; (4) genetic testing of embryos; (5) indicated fertility medications; (6) gamete donation; and (7) other Secretary-determined services. This section also adds new requirements under the Public Health Service Act for plans offering fertility benefits in the individual and small group markets by (1) prohibiting financial requirements or treatment limitations for such benefits that are more restrictive than those for substantially all medical and surgical benefits, with no separate cost-sharing or limits applicable only to fertility; (2) barring denial of fertility benefits due to lack of an infertility diagnosis; and (3) requiring issuers using utilization management tools for fertility care to analyze and report on them to the Secretary and Comptroller General for the first five plan years beginning one year after enactment (with Comptroller General reports to Congress assessing compliance). The amendments apply to plan years beginning one year after enactment.