This bill creates a uniform federal baseline requiring health plans that offer obstetrical services to also cover fertility treatment. It inserts parallel mandates into the Public Health Service Act, ERISA, and the Internal Revenue Code and instructs federal programs to align with the same standard.
For plan sponsors, insurers, federal health programs, and reproductive health providers, the bill replaces the current patchwork of state rules and employer practices with a single set of statutory duties: a broad definition of covered fertility services, limits on higher cost‑sharing for those services, notice requirements, and explicit prohibitions on incentives or provider restrictions that would limit access.
At a Glance
What It Does
Amends federal insurance law to require group and individual health coverage that already covers obstetrical services to also cover fertility treatment, defines covered services broadly (gamete preservation, ART, genetic testing, fertility medications, donation), and bars higher cost‑sharing or discriminatory limitations for those services. It directs agencies to issue implementing regulations and requires plans and issuers to provide written notice to enrollees.
Who It Affects
Private insurers and group health plans (including ERISA‑governed and self‑insured employer plans), federal programs and contracts (FEHB, TRICARE, VA), Medicare and state Medicaid programs, reproductive medicine providers, and patients seeking fertility care (including those without an ASRM infertility diagnosis).
Why It Matters
The bill would create a nationally uniform coverage floor for fertility services where previously coverage depended on state law, employer choice, or benefit design. That standard will change benefit design, compliance obligations, provider contracting, and public‑program budgets across jurisdictions.
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What This Bill Actually Does
The bill adds a new, uniform statutory requirement to multiple bodies of federal law so that any health coverage that includes obstetrical services must also include fertility treatment. To achieve that, it inserts a new section into the Public Health Service Act (identified in the bill text by the statutory label it creates), adds a parallel ERISA requirement for employer plans, and places an analogous provision into the Internal Revenue Code for tax‑qualified group plans.
Those parallel amendments are meant to capture both fully insured and many self‑insured employer plans.
The statutory definition of “fertility treatment” is intentionally broad: the bill lists preservation of oocytes, sperm, or embryos; several forms of artificial insemination; assisted reproductive technologies such as in vitro fertilization; genetic testing of embryos; fertility medications (including OTC when clinically indicated); gamete donation; and a catch‑all that lets the Secretary of Health and Human Services add related services. Coverage must be supplied when a treating clinician determines the treatment appropriate, and the bill expressly states that an ASRM diagnosis of infertility is not a prerequisite.On benefit design, the statute forbids plans from imposing greater deductibles, coinsurance, or other limitations on covered fertility services than apply to other medical services; where a plan’s limit would be more favorable to patients, that more favorable limit can apply.
The Secretary is authorized to issue interim final regulations specifically on the cost‑sharing restriction without following the usual notice‑and‑comment rulemaking timeline. The law also lists operational prohibitions: plans may not offer incentives to dissuade patients from seeking fertility care, may not bar providers from discussing options, may not reduce provider reimbursement in retaliation for providing care, and may not apply coverage exclusions or discriminatory practices prohibited under federal civil‑rights statutes.The bill also amends major federal programs and contracts.
It requires FEHB contractors to include fertility coverage when their plans include obstetrical benefits and limits copayments/deductibles to no higher than those for obstetrical care; TRICARE must mirror those cost‑sharing rules and promulgate implementing regs; VA is required to establish a joint application process so veterans and their spouses/partners can access fertility services and to issue regulations within 18 months. For Medicaid, state plans must ensure medical assistance for fertility treatment consistent with the new federal standard (with an October 1, 2026 effective date and a state legislative delay option).
Medicare’s benefit package is expanded to list fertility treatment as a covered item, directs payment equal to 100 percent of the lesser of actual charge or applicable fee schedule amount, and waives the Medicare deductible for fertility services starting January 1, 2026.Implementation timing is frontloaded: the insurance law amendments apply to plan years beginning six months after enactment (with a delayed application where collective bargaining agreements require it); FEHB changes take effect for contracts entered or renewed 180 days after enactment; Medicaid and Medicare receive their own effective‑date language; and HHS and Defense are given authority to issue regulations and guidance to operationalize the new obligations.
The Five Things You Need to Know
The mandate applies only to plans that already cover obstetrical services — it does not require obstetrical coverage where none exists.
The statutory definition of fertility treatment explicitly covers gamete preservation (oocytes, sperm, embryos) and assisted reproductive technologies including in‑vitro fertilization and embryo genetic testing.
The bill bars higher cost‑sharing for covered fertility services: plans may not impose deductibles or coinsurance that exceed what they apply to other medical services, and HHS must issue interim final regulations on that point.
Parallel amendments are added to three places in federal law — the Public Health Service Act, ERISA, and the Internal Revenue Code — to sweep in insured and many self‑insured group plans.
Under the bill Medicare coverage changes include 100% payment (subject to fee schedule comparators) and an explicit waiver of the Medicare deductible for fertility treatment, effective January 1, 2026.
Section-by-Section Breakdown
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Federal baseline for private insurance coverage of fertility treatment
This new PHSA section is the bill’s operational core for insured markets: it defines fertility treatment broadly, requires coverage whenever a plan covers obstetrical services and a provider deems treatment appropriate, and imposes the cost‑sharing parity rule. Practically, state‑regulated insurers that currently cover obstetrics will have to expand benefits to include the listed fertility services and update plan materials and provider contracts to comply with the parity and non‑discrimination rules.
Direct obligation on employer‑sponsored plans (including many self‑insured plans)
By inserting an analogous provision into ERISA, the bill reaches employer plans governed by federal ERISA rules, including many self‑insured arrangements. That placement reduces reliance on varying state mandates and places compliance responsibility on plan administrators and sponsors. The text preserves the ability of plans and issuers to negotiate reimbursement levels with providers, but limits plan design choices on patient cost‑sharing and enjoins practices that would discourage provision of care.
Tax‑code parallel to ensure group plan coverage consistency
The addition to the Internal Revenue Code aligns requirements for group plans that are relevant to tax‑qualified status and plan reporting. Including a parallel IRC provision helps prevent a carve‑out where a plan’s tax treatment could otherwise incentivize noncompliance.
Federal employees’ plans must offer fertility coverage aligned with the standard
FEHB contracts must include fertility coverage if they include obstetrical benefits, and the amendment caps copayment/deductible exposure at no more than what applies to obstetrical care. Contracting officers and carriers will need to update contract terms and member materials, and the Office of Personnel Management must oversee compliance for FEHB carriers.
TRICARE required to match cost‑sharing parity and issue regulations
The bill directs the Department of Defense to set TRICARE cost‑sharing consistent with the PHSA parity rule and to issue implementing regulations. TRICARE administrators will have to modify benefit tables, network arrangements, and potentially pharmacy benefit management to reflect expanded medication coverage tied to fertility care.
VA must provide fertility treatment and create a joint‑application process
The VA must furnish fertility services to veterans and their spouses or partners via a joint application process and issue implementing regulations within 18 months. That creates a programmatic obligation for the VA to stand up intake and clinical pathways and decide how services are delivered (in‑house vs community care).
Medicaid state plan requirement and Medicare coverage/payment adjustments
Medicaid state plans must include medical assistance for fertility treatment consistent with the PHSA definition, with an October 1, 2026 effective date and a statutory delay option for states needing legislative changes. Medicare’s statute is amended to list fertility treatment as covered, set payment equal to 100% of the lower of charge or fee schedule amount, and to waive the deductible for these services effective January 1, 2026, which will have immediate budgetary and administrative implications for CMS and providers billing Medicare.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Patients seeking fertility care (including those without a formal ASRM infertility diagnosis): they gain an enforceable right to coverage when their plan already covers obstetrical services, widening access to preservation, ART, genetic testing, donor services, and fertility medications.
- Veterans and their spouses or partners: the VA obligation and joint‑application process create an explicit pathway to receive fertility services through VA programs where they were previously uneven or unavailable.
- Public program beneficiaries (Medicare and Medicaid enrollees): Medicare’s explicit coverage, payment changes, and Medicaid state‑plan requirement extend access within federal programs that previously excluded or limited fertility services.
- Reproductive medicine providers and clinics: insurers will be required to cover more services, creating a larger payer base and potentially increasing patient volumes and revenue streams for services previously self‑pay.
Who Bears the Cost
- Insurers and self‑insured employers: adding covered benefits and limiting cost‑sharing choices likely increase claims costs and administrative work to redesign benefits, update provider contracts, and manage utilization.
- Federal programs and taxpayers: Medicare’s 100% payment posture and the VA/FEHB/TRICARE expansions create direct federal cost exposure; Medicaid’s coverage requirement will increase state Medicaid spending pressure, though states have a limited delay option.
- State Medicaid programs and legislatures: states must adjust plans, budgets, and potentially state law; the statutory delay mechanism pushes implementation timing but not the underlying obligation.
- Plan administrators and HR departments: new notice requirements, benefit communications, and implementation of parity rules add compliance burdens, particularly for multi‑state employers and those with collective bargaining agreements.
Key Issues
The Core Tension
The central dilemma the bill creates is straightforward: it advances equitable access to fertility care by imposing a uniform federal coverage floor, but doing so shifts costs, administrative burdens, and access management onto insurers, employers, federal and state budgets, and provider networks — and it leaves regulators to reconcile clinical discretion, network design, and rapid rulemaking with durable, equitable access in practice.
Several implementation and policy tensions flow from this design. First, the bill conditions the new entitlement on existing obstetrical coverage; states and employers that do not cover obstetrics remain outside the mandate, so coverage expansion will be uneven.
Second, the cost‑sharing parity rule directs parity in patient payments but leaves reimbursement levels and network management largely in private hands; insurers can still negotiate rates or limit participating providers, which may reduce access in practice even where coverage exists. Third, the Secretary’s authority to issue interim final regulations for cost‑sharing — bypassing standard notice and comment for that narrow topic — accelerates implementation but increases litigation risk and uncertainty for plan administrators.
Operationally, the mixture of federal authorities creates multiple transition clocks and exceptions (six‑month plan‑year effective dates, collective bargaining protections, FEHB 180‑day timing, Medicaid’s state legislative delay, Medicare’s January 1, 2026 start). That patchwork raises administrative complexity for multi‑jurisdictional employers, insurers that participate in federal programs, and states trying to budget for new services.
Capacity constraints also matter: expanded coverage without concurrent investments to increase provider capacity for ART, genetic testing, and gamete preservation could lead to longer wait times or regional access gaps. Lastly, the bill does not address conscience‑based or religious accommodation claims from providers or institutions; absence of explicit accommodations may prompt future legal challenges balancing nondiscrimination against religious liberty claims.
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