1374.55.
(a) A health care service plan contract that covers hospital, medical, or surgical expenses (1) A large group health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 2024, shall provide coverage for the diagnosis and treatment of infertility and fertility services. The coverage required by this subdivision
section includes services, of completed oocyte retrievals with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine (ASRM), using single embryo transfer when recommended and medically appropriate. Every health care service plan shall include notice of the coverage specified in this section in the plan’s evidence of coverage.(2) A small group health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 2024, shall offer coverage for the diagnosis and treatment of infertility and fertility services. This paragraph shall not be construed
to require a small group health care service plan contract to provide coverage for infertility services.
(3) An individual health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 2024, shall offer coverage for the diagnosis and treatment of infertility and fertility services. This paragraph shall not be construed to require an individual health care service plan contract to provide coverage for infertility services.
(4) A health care service plan shall include notice of the coverage specified in this section in the plan’s evidence of coverage.
(b) For purposes of this section,
“infertility” means a condition
disease, condition, or status characterized by any of the following:
(1) A licensed physician’s findings, based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors. This definition shall not prevent testing and diagnosis of infertility prior to the 12-month or 6-month period to establish infertility in paragraph (3).
(2) A person’s inability to reproduce either as an individual or with their partner without medical intervention.
(3) The failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. For purposes of this section, “regular, unprotected
sexual intercourse” means no more than 12 months of unprotected sexual intercourse for a person under 35 years of age or no more than 6 months of unprotected sexual intercourse for a person 35 years of age or older. Pregnancy resulting in miscarriage does not restart the 12-month or 6-month time period to qualify as having infertility.
(c) The contract may not include any of the following:
(1) Any exclusion, limitation, or other restriction on coverage of fertility medications that are different from those imposed on other prescription medications.
(2) Any exclusion or denial of coverage of any fertility services based on a covered individual’s participation in fertility services provided by or to a third party. For
purposes of this section, “third party” includes an oocyte, sperm, or embryo donor, gestational carrier, or surrogate that enables an intended recipient to become a parent.
(3) Any deductible, copayment, coinsurance, benefit maximum, waiting period, or any other limitation on coverage for the diagnosis and treatment of infertility, except as provided in subdivision (a) that are different from those imposed upon benefits for services not related to infertility.
(d) This section does not in any way deny or restrict any existing right or benefit to coverage and treatment of infertility or fertility services under an existing law, plan, or policy.
(e) Consistent with Section 1365.5, coverage for the treatment of
infertility and fertility services shall be provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation. This subdivision shall not be construed to interfere with the clinical judgment of a physician and surgeon.
(f) This section does not apply to Medi-Cal managed care health care service plan contracts or any entity that enters into a contract with the State Department of Health Care Services for the delivery of health care services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), Chapter 8.75 (commencing with Section 14591), or Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare
and Institutions Code.