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Marginalia
Code · California · Insurance Code

§ 10119.6

709 words·~3 min read·/ca/insurance-code/10119-6

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(1)A large group health insurance policy that is issued, amended, or renewed on or after January 1, 2026, shall provide coverage for the diagnosis and treatment of infertility and fertility services, including a maximum of three 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.
(2)A small group health insurance policy that is issued, amended, or renewed on or after January 1, 2026, 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 insurance policy to provide coverage for infertility services.
(3)A health insurer shall include notice of the coverage specified in this section in the insurer’s evidence of coverage.
(4)This section shall not apply to Medicare supplement or specialized health insurance policies.
(b)For purposes of this section, “infertility” means a 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 before 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 policy 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)This section applies to every health insurance policy that is issued, amended, or renewed to residents of this state regardless of the situs of the contract.
(f)Consistent with Section 10140, 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.
(g)This section shall not apply to a religious employer, as defined in Section 10123.196.
(h)This section shall not apply to a health care benefit plan or policy entered into with the Board of Administration of the Public Employees’ Retirement System pursuant to the Public Employees’ Medical and Hospital Care Act (Part 5 (commencing with Section 22750) of Division 5 of Title 2 of the Government Code) until July 1, 2027.
(1)Until January 1, 2027, the commissioner may issue guidance regarding compliance with this section, and that guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(2)The department shall consult with the Department of Managed Health Care and stakeholders in issuing the guidance specified in paragraph (1).
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