H.R. 8119: Helping to Optimize Patients’ Experience with Fertility Services Act

This bill, known as the Helping to Optimize Patients’ Experience with Fertility Services Act, aims to ensure that group health plans and health insurance providers cover infertility treatments, specifically focusing on both infertility and iatrogenic infertility. Here is a breakdown of the key provisions presented in the bill:

Coverage Requirements

• The bill requires that any group health plan or health insurance issuer that provides coverage for obstetrical services must also include:
• Treatment for infertility if it includes obstetrical services.
• Standard fertility preservation services when medical treatments are expected to cause infertility.

Definitions

Key terms defined in the bill include:

• Infertility: A condition characterized by the inability to achieve pregnancy after 12 months of unprotected intercourse, or after medical treatment under a physician.
• Iatrogenic Infertility: Fertility impairment caused by medical procedures such as surgery, radiation, chemotherapy, or other invasive treatments.
• Treatments: Includes procedures like in vitro fertilization (IVF), egg and embryo handling, and other methods aimed at facilitating pregnancy.

Comprehensive Coverage

The act mandates that health plans provide comprehensive coverage for infertility treatments, ensuring that these services meet standards set by federal and state agencies. This coverage is contingent upon the participant being diagnosed with infertility or iatrogenic infertility.

Financial Requirements and Limitations

Coverage might include some limits and cost-sharing requirements (like copayments and deductibles) as long as they are not more restrictive than those applied to standard medical and surgical benefits.

Prohibited Actions

The bill prohibits group health plans and insurers from:

• Encouraging participants to forgo their entitled infertility treatments.
• Restricting discussions between providers and participants about infertility treatments.
• Reducing reimbursement for providers based on the provision of these treatments.

Utilization Management

For plans that use utilization management tools (to control the use of healthcare services), the bill requires them to undertake analyses of these tools and their application specifically to infertility treatments. This analysis must be submitted annually for the first five years after the bill's enactment.

Enforcement and Compliance

Health insurance issuers that fail to comply with these new coverage requirements may face civil penalties. The Secretary of Health will be responsible for enforcement and can assess penalties for daily non-compliance concerning both coverage and analytical reporting obligations.

Notice Requirements

Health plans are required to inform participants about the newly mandated infertility treatment coverage starting from the second plan year after enactment of the bill.

Effective Date

The provisions of the bill will become applicable to plan years starting on or after January 1, 2027.

Relevant Companies

• UNH (UnitedHealth Group) - As a major health insurance provider, UnitedHealth Group would need to adjust its coverage policies to comply with the new mandates outlined in the bill.
• ANTM (Anthem, Inc.) - As another significant player in health insurance, Anthem would likely have to revise its plans and potentially manage the impact of new coverage requirements on its operations and costs.
• HUM (Humana Inc.) - Humana will have to implement changes to health insurance plans to include the coverage specified in the legislation, affecting their policy structures.