§ 1374.55. — 1374.55. (Amended by Stats. 2025, Ch. 21, Sec. 8.)

California § 1374.55.

• Jurisdiction: California
• Code HSC: Health and Safety Code - HSC
• Div. 2.: DIVISION 2. LICENSING PROVISIONS
• Ch. 2.2.: CHAPTER 2.2. Health Care Service Plans
• Art. 5.: ARTICLE 5. Standards

Text

(a)
(1)
A large group health care service plan contract, except a specialized health care service plan contract, 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 care service plan contract, except a specialized health care service plan contract, 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 care service plan contract to provide coverage for infertility services.
(3)
A health care service plan shall include notice of the coverage specified in this section in the plan’s evidence of coverage.
(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 of infertility 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 contract 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)
Consistent with Section 1365.5, 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.
(f)
This section does not apply to Medi-Cal managed care health care service plan contracts or any entity that enters into a contract with the State Department of Health Care Services for the delivery of health care services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), Chapter 8.75 (commencing with Section 14591), or Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code.
(g)
This section shall not apply to a religious employer, as defined in Section 1367.25.
(h)
This section shall not apply to a health care benefit plan or contract 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.
(i)
(1)
Until January 1, 2027, the director 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 Insurance and stakeholders in issuing the guidance specified in paragraph (1).

Legislative History

Amended by Stats. 2025, Ch. 21, Sec. 8. (AB 116) Effective June 30, 2025.