Is Infertility an Essential Health Benefit?

[rocknrolls2]

A client maintains a self-funded group health plan for its employees. There is a proposal to amend the plan to subject reimbursement for infertility services to a lifetime maximum of $25,000 per family  for in-network and out-of-network care. Are infertility services considered an essential health benefit which would make the proposed lifetime limit illegal?

[leevena]

Self funded plans are not subject to the Essential Health Benefit requirements.  If a self funded plan does offer an Essential Health Benefit, then it may not cap the benefit.  There is no standard definition of infertility services.  Essential Health Benefits can differ from state to state depending on what is used as a definition.  So, there is no way to to give you an answer to your question because there is not sufficient information here.  But, I would go to the plan administrator for their opinion.

[Chaz]

You would need to look at the benchmark plan in the applicable state to make that determination.

[CEB]

Self Funded plans select the state for their plan. For example in Texas most employers select Utah for their because they are more relaxed. Self-Funded plans still have a state they have to operate under, you would need to understand that state rules like chaz was mentioning.