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In 2001, the Family Building Act was signed into law in New Jersey. The law requires that New Jersey health insurance policies, riders and endorsements:
- Cover groups other than small employers (less than 50 employees) and provide pregnancy-related benefits
- Cover the cost of the diagnosis and treatment of infertility
The law defines infertility as the disease or condition that results in the abnormal function of the reproductive system such that:
- A male is unable to impregnate a female
- A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse
- A female with a male partner and 35 years of age or older is unable to conceive after six months of unprotected sexual intercourse
- A female without a male partner and under 35 years of age is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision
- A female without a male partner and over 35 years of age is unable to conceive after six failed attempts of intrauterine insemination under medical supervision
- The male or female is medically sterile
- The female is unable to carry a pregnancy to live birth
What Does the Family Building Act Cover?
Infertility coverage includes, but is not limited to, payment of benefits for the following services and procedures:
- Artificial insemination with no limit as to the number of cycles
- Assisted hatching
- Diagnosis and diagnostic tests
- Fresh and frozen embryo transfer
- Four completed egg retrievals per lifetime of the covered person
- Where a donor is used in the egg retrieval, the medical costs of the donor shall be covered until the donor is released from treatment by the reproductive endocrinologist
- Egg retrievals where the cost was not covered by any carrier shall not count in determining whether the four completed egg retrieval limit has been met
- Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
- Intracytoplasmic sperm injections (ICSI)
- In vitro fertilization (IVF), including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate
- Medications, including injectable infertility medications, even if the contract or policy does not provide prescription drug benefits. Where a contract or policy provides both prescription drug and medical and hospital benefits, infertility drugs shall be covered under the prescription drug coverage.
- Ovulation induction
- Surgery, including microsurgical sperm aspiration
Procedures must be performed at facilities that conform with ACOG and ASRM guidelines.
Patients must be younger than 46 years of age.
What is Not Covered?
- Nonmedical costs of egg or sperm donor
- Infertility treatments that are experimental or investigational
- Infertility resulting from voluntary sterilization procedures
- Employers with fewer than 50 employees do not have to provide coverage.
- Religious employers are not required to cover infertility treatment.
- Employers who self-insure are exempt from the requirements of the law.
Our financial counselors would be happy to answer any questions you have about your insurance and financial options.