H.R. 4648 — Access to Fertility Treatment and Care Act

This section requires group health plans and health insurance issuers offering group or individual health insurance coverage that provide obstetrical services to cover fertility treatment—including preservation of oocytes, sperm, or embryos; artificial insemination; assisted reproductive technology such as in vitro fertilization; genetic testing of embryos; fertility medications; and gamete donation—as determined appropriate by a provider at a compliant facility, regardless of infertility diagnosis. Coverage must apply cost-sharing and limitations no greater than those for other medical services; prohibits incentives to forgo treatment, restrictions on provider discussions, provider penalties, or discrimination under specified civil rights laws; requires written notice in plan materials by the earlier of the first post-regulation mailing, yearly packet, or January 1, 2027 (and annually thereafter or upon enrollment); and authorizes the Secretary to determine additional services and issue interim final regulations on cost-sharing. (Thus, plans and issuers may negotiate reimbursement levels but cannot mandate treatment.)

This section requires Federal Employees Health Benefits Program (FEHBP) contracts to cover fertility treatments (as defined in section 2799A-11(b) of the Public Health Service Act (PHS Act)) in a manner consistent with PHS Act section 2799A-11 if the contract covers obstetrical benefits. (1) Such coverage under plans described in 5 U.S.C. § 8903 or § 8903a may not be subject to copayments or deductibles greater than those applicable to obstetrical benefits; and (2) preexisting condition exclusion limitations do not prevent inclusion of these required terms. The requirements apply to contracts entered into or renewed for contract years beginning on or after 180 days after enactment.

This section requires any health care plan under the TRICARE program (i.e., the Department of Defense's health care program for active duty service members, retirees, and their families) to provide coverage for fertility treatment—defined as in section 2799A–11(b) of the Public Health Service Act—if the plan covers obstetrical benefits, with implementation consistent with section 2799A–11 of that Act. The section further directs the Secretary of Defense to establish cost-sharing requirements consistent with section 2799A–11(d) of the Public Health Service Act and to prescribe implementing regulations.

This section establishes a new fertility treatment benefit under 38 U.S.C. §1720M, requiring the Secretary of Veterans Affairs to furnish fertility treatment services (as defined in section 2799A–11(b) of the Public Health Service Act, i.e., counseling, diagnosis, and treatment including in vitro fertilization) to a veteran or the veteran's spouse or partner upon their joint application through a VA-prescribed process. The section further directs the Secretary to prescribe implementing regulations within 18 months of enactment.

This section requires state Medicaid plans to include fertility treatment—provided in accordance with requirements of section 2799A–11(b) of the Public Health Service Act—in family planning services under SSA section 1905(a)(4)(C), which are eligible for a 90% federal medical assistance percentage (FMAP) under SSA section 1903(a)(5). It makes a conforming amendment to section 1903(a)(5) specifying that the 90% FMAP applies to such family planning services and supplies described in section 1905(a)(4)(C). (As background, Medicaid family planning services support access to contraception, counseling, and related care for low-income individuals.) The requirements take effect on October 1, 2026, with a permitted delay until the first calendar quarter after the first regular state legislative session ending within one year of enactment if state legislation is required.

This section adds fertility treatment (as defined in section 2799A–11(b) of the Public Health Service Act) to the list of Medicare Part B covered services (1861(s)(2)(KK)), effective for services furnished on or after January 1, 2026. It provides payment at 100% of the lesser of the actual charge or the physician fee schedule amount under section 1848 (1833(a)(1)); waives the Part B deductible (1833(b)); applies the physician fee schedule to such services (1848(j)(3)); and makes a conforming amendment to exclude such treatment from Medicare coverage restrictions (1862(a)(1)(A)). (Thus, Medicare beneficiaries incur no out-of-pocket costs for covered fertility treatment.)