Does Insurance Cover IVF in California?

The cost of in vitro fertilization (IVF) treatments is a significant financial concern for many individuals and couples. This article clarifies the landscape of insurance coverage for IVF in California, outlining relevant state laws, how to understand specific insurance plans, the scope of covered services, and the steps involved in accessing these benefits.

California’s Infertility Coverage Mandate

California has laws addressing insurance coverage for infertility treatment. Senate Bill 729 (SB 729), signed into law in September 2024, impacts this coverage. This legislation mandates that certain health plans provide coverage for the diagnosis and treatment of infertility, including IVF, for policies issued, amended, or renewed on or after January 1, 2026.

The law broadens the definition of “infertility.” It now includes a licensed physician’s findings based on a patient’s medical history, age, and diagnostic testing. It also encompasses a person’s inability to reproduce without medical intervention, or the failure to establish a pregnancy or carry one to live birth after a specific period of unprotected sexual intercourse (12 months for those under 35, or six months for those 35 and older). This ensures equitable access to care, including for LGBTQ+ individuals and single parents by choice.

Understand which types of health plans are subject to this mandate and which are exempt. Fully insured large group health plans, covering 101 or more employees, are required to include this coverage. Conversely, self-funded employer plans, regulated by federal law under the Employee Retirement Income Security Act (ERISA), are exempt from state mandates.

Small group plans, covering 100 or fewer employees, are not mandated to include IVF coverage. Instead, insurers must offer employers the option to add this coverage to their plans, often as a rider. Religious employers meeting specific criteria are also exempt from the mandate.

Understanding Your Specific Insurance Plan

Determining your individual plan’s coverage for IVF treatments starts by reviewing your Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents. These documents provide information about your policy’s benefits, limitations, and exclusions.

Contact your insurance provider directly. The member services phone number is on your insurance card. You can also reach out to your employer’s human resources or benefits administrator for assistance.

When communicating with your insurer, ask questions about coverage. Inquire whether infertility diagnosis and treatment are covered, and if there are criteria for coverage, such as duration of infertility or age limits. Also ask about requirements for prior authorization or referrals.

Ask about financial implications, including deductibles, co-pays, and out-of-pocket maximums related to infertility treatment. Clarify any network restrictions for fertility specialists or clinics, as using out-of-network providers may result in higher costs. Always request information, such as coverage confirmations or policy excerpts, in writing.

Covered Services and Common Exclusions

California’s mandate requires coverage for many infertility services. This includes diagnostic testing, such as blood tests, imaging, and semen analysis, to identify underlying causes. Assisted Reproductive Technologies (ART) like In Vitro Fertilization (IVF) are included.

The law requires coverage for a maximum of three completed oocyte (egg) retrievals with unlimited embryo transfers, following American Society for Reproductive Medicine (ASRM) guidelines for single embryo transfer when medically appropriate. Fertility medications for ovarian stimulation must be covered like other prescription medications.

Despite the mandate, certain services or situations may be excluded or limited by plans. Procedures considered experimental or not yet recognized as standard medical practice might not be covered. Reversal of voluntary sterilization procedures is excluded.

Common exclusions include:
Surrogacy services.
Gestational carrier services.
Acquisition of donor eggs, sperm, or embryos, though the procedure using donor gametes might be covered.
Embryo storage.

Plans may also impose limitations on the number of IVF cycles or set age limits for treatment. These limitations must be applied consistently with other medical benefits.

Accessing Your IVF Coverage

After understanding your insurance coverage, access care by consulting with a fertility specialist. A medical diagnosis of infertility from a qualified physician is required to initiate coverage. This specialist will develop a treatment plan tailored to your needs.

Obtaining prior authorization from your insurance company before starting treatment is a key procedural step. This usually involves submitting your medical records and the proposed treatment plan for review and approval by the insurer. Many fertility clinics have dedicated financial or patient advocate teams that can assist with this process.

Work closely with your fertility clinic, as they often handle insurance verification, billing, and claims submission. If your plan is a Health Maintenance Organization (HMO), you may need a referral from your primary care physician to see a fertility specialist. Ensure all referrals are in place before appointments or procedures.

Maintain detailed records throughout your treatment journey. Document all communications with your insurance company and the clinic, including dates, names of individuals spoken to, and summaries of discussions. Keep copies of all medical reports, treatment plans, and billing statements. Understanding your potential out-of-pocket costs, including deductibles, co-pays, and co-insurance, helps manage care finances.