[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8821 Introduced in House (IH)]
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118th CONGRESS
2d Session
H. R. 8821
To ensure coverage for the treatment of infertility for certain
conditions.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 25, 2024
Mrs. Chavez-DeRemer (for herself, Mr. Nunn of Iowa, Ms. Wild, and Ms.
Wasserman Schultz) introduced the following bill; which was referred to
the Committee on Education and the Workforce
_______________________________________________________________________
A BILL
To ensure coverage for the treatment of infertility for certain
conditions.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Helping to Optimize Patients'
Experience with Fertility Services Act'' or the ``HOPE with Fertility
Services Act''.
SEC. 2. ENSURING BENEFITS FOR TREATMENT OF INFERTILITY AND IATROGENIC
INFERTILITY.
(a) In General.--Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et
seq.) is amended by inserting after section 714 the following:
``SEC. 714A. STANDARDS RELATING TO BENEFITS FOR TREATMENT OF
INFERTILITY AND IATROGENIC INFERTILITY.
``(a) In General.--A group health plan or a health insurance issuer
offering group health insurance coverage shall ensure that such plan or
coverage provides coverage for infertility or iatrogenic infertility
treatments, including--
``(1) the treatment of infertility, if such plan or
coverage provides coverage for obstetrical services; and
``(2) standard fertility preservation services when a
medically necessary treatment described in subparagraph (A),
(B), (C), or (D) of subsection (b)(1) causes, or is expected to
cause, iatrogenic infertility.
``(b) Definitions.--In this section:
``(1) Iatrogenic infertility.--The term `iatrogenic
infertility' means an impairment of fertility due to damage of
reproductive organs and processes resulting from--
``(A) a surgical or other invasive medical
procedure as a result of an injury or life-threatening
illness, or involving a reproductive organ or process
in a manner likely to cause damage to such organ or
process;
``(B) radiation therapy;
``(C) chemotherapy; or
``(D) myeloablative conditioning.
``(2) Infertility.--The term `infertility' means a disease
or condition characterized by--
``(A) the inability to achieve spontaneous
pregnancy without medical treatment after a period of
at least 12 consecutive months of unprotected sexual
intercourse;
``(B) the inability to achieve pregnancy after
receiving standard clinical treatment protocols under
the supervision of a treating physician who is a board-
certified reproductive endocrinologist or obstetrician-
gynecologist;
``(C) being incapable of reproduction to live birth
based on medical and reproductive history, age,
physical findings or diagnostic testing of the
individual, as determined by a treating physician; or
``(D) the inability to achieve spontaneous
pregnancy on account of a diagnosed condition that is a
disorder of ovulation, or a testicular or hormonal
disease or disorder.
``(3) Infertility or iatrogenic infertility treatment.--The
term `infertility or iatrogenic infertility treatment' means
treatments or procedures with the intent of facilitating a
pregnancy, including--
``(A) such treatments or procedures that involve
the handling of human egg, sperm, and embryo outside of
the body, including in vitro fertilization and
maturation, egg and embryo cryopreservation, egg and
embryo donation, and intracytoplasmic sperm injection;
or
``(B) such treatments or procedures that do not
involve the handling of human egg, sperm, and embryo
outside of the body, including ovulation induction,
genetic screening and diagnosis, sperm
cryopreservation, and intrauterine insemination.
``(c) Required Coverage.--A group health plan and a health
insurance issuer offering group health insurance coverage that includes
coverage for obstetrical services shall provide comprehensive coverage
for infertility or iatrogenic infertility treatments, as determined by
the Secretary in consultation with relevant stakeholders, provided to a
participant or beneficiary if--
``(1) the participant or beneficiary has infertility,
including iatrogenic infertility; and
``(2) the treatment or service is performed at a medical
facility that is in compliance with standards set by
appropriate Federal and State agencies.
``(d) Financial Requirements and Treatment Requirements.--Any
coverage provided by a group health plan or health insurance issuer in
accordance with this section may be subject to coverage limits (such as
medical necessity, pre-authorization, or pre-certification) and cost-
sharing requirements (such as coinsurance, copayments, and
deductibles), as required under the group health plan or health
insurance coverage, that are no more restrictive than the predominant
coverage limits and cost-sharing requirements applied to substantially
all medical and surgical benefits covered under the plan or coverage.
``(e) Prohibitions.--A group health plan and a health insurance
issuer offering group health insurance coverage may not--
``(1) provide incentives (monetary or otherwise) to a
participant or beneficiary to encourage such participant or
beneficiary not to be provided infertility or iatrogenic
infertility treatments to which such participant or beneficiary
is entitled under this section, or to providers to induce such
providers not to provide such treatments to qualified
participants and beneficiaries;
``(2) prohibit a provider from discussing with a
participant or beneficiary infertility or iatrogenic
infertility treatments or medical treatment options required to
be covered under this section; or
``(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider provided
infertility or iatrogenic infertility treatment services to a
participant or beneficiary in accordance with this section.
``(f) Rule of Construction.--Nothing in this section shall be
construed to--
``(1) require a participant or beneficiary in a group
health plan or group health insurance coverage to undergo
infertility or iatrogenic infertility treatments;
``(2) impact the use by a group health plan or a health
insurance issuer offering group health insurance coverage of
utilization management tools; or
``(3) prevent a group health plan or a health insurance
issuer offering group health insurance coverage from
contracting with providers as to the level and type of
reimbursement with a provider for care provided in accordance
with this section.
``(g) Utilization Management Tools Requirements.--
``(1) In general.--In the case of a group health plan or a
health insurance issuer offering group health insurance
coverage that imposes utilization management tools on
infertility and iatrogenic infertility treatment benefits, for
the first 5 plan years that begin after the date of enactment
of the Helping to Optimize Patients' Experience with Fertility
Services Act, such plan or issuer shall perform and document
analyses of the design and application of the utilization
management tool such analysis and the following information:
``(A) The specific plan or coverage terms or other
relevant terms regarding the utilization management
tools and a description of all infertility or
iatrogenic infertility treatment benefits, to which
each such term applies in each respective benefits
classification.
``(B) The factors used to determine that the
utilization management tool will apply to infertility
or iatrogenic infertility treatment benefits.
``(C) The evidentiary standards used for the
factors identified under subparagraph (B), when
applicable, provided that every factor shall be
defined, and any other source or evidence relied upon
to design and apply the utilization management tool to
infertility and iatrogenic infertility treatment
benefits.
``(D) An analysis demonstrating that the processes,
strategies, evidentiary standards, and other factors
used to apply the utilization management tools to
infertility and iatrogenic infertility treatment
benefits as written and in operation, are consistent
with, and are applied no more stringently than with
clinical guidelines for infertility or iatrogenic
infertility treatments.
``(E) The specific findings and conclusions reached
by the group health plan or health insurance issuer
with respect to the health insurance coverage,
including any results of the analyses described in this
paragraph that indicate that the plan or coverage is or
is not in compliance with this section.
``(2) Submission process.--
``(A) Annual submission.--A group health plan or
health insurance issuer offering group health insurance
coverage shall submit to the Secretary the analyses
described in paragraph (1) annually for first 5 plan
years that begin after the date of enactment of the
Helping to Optimize Patients' Experience with Fertility
Services Act. For subsequent plan years, the Secretary
may request that a group health plan or a health
insurance issuer offering group health insurance
coverage submit the analysis described in paragraph (1)
in the case of potential violations of this section or
complaints regarding noncompliance with this section
that concern utilization management tools and any other
instances in which the Secretary determines
appropriate.
``(B) Additional information.--If the Secretary
concludes that a group health plan or health insurance
issuer has not submitted sufficient information for the
Secretary to review the analysis described in paragraph
(1), the Secretary shall specify to the plan or issuer
the information the plan or issuer is required to
submit pursuant to subparagraph (A). Nothing in this
subparagraph shall require the Secretary to conclude
that a group health plan or health insurance issuer is
in compliance with this section solely based upon the
inspection of the analyses described in paragraph (1),
as requested under subparagraph (A).
``(3) Required action.--
``(A) In general.--If, after review of the analyses
described in paragraph (1), the Secretary notifies the
group health plan or health insurance issuer that such
plan or issuer is not in compliance with this section,
the plan or issuer--
``(i) shall specify to the Secretary the
actions the plan or issuer will take to be in
compliance with this section and provide to the
Secretary additional analyses described in
paragraph (1) that demonstrate compliance with
this section not later than 45 days after the
initial notification by the Secretary that the
plan or issuer is not in compliance; and
``(ii) following the 45-day corrective
action period under clause (i), if the
Secretary makes a final determination that the
plan or issuer still is not in compliance with
this section, not later than 7 days after such
determination, shall notify all individuals
enrolled in the applicable plan or health
insurance coverage that such plan or coverage
has been determined to be not in compliance
with this section.
``(B) Exemption from disclosure.--Documents or
communications produced in connection with the
Secretary's recommendations to a group health plan or
health insurance issuer shall not be subject to
disclosure pursuant to section 552 of title 5, United
States Code.
``(4) Report.--For plan years beginning on or after January
1, 2026, the Secretary shall submit to Congress, and make
publicly available, a report that contains--
``(A) a summary of the analysis submitted under
paragraph (1), including the identity of each group
health plan or health insurance issuer offering health
insurance coverage that is determined to be not in
compliance after the final determination by the
Secretary described in paragraph (3)(A)(ii);
``(B) the Secretary's conclusions as to whether
each group health plan or health insurance issuer
submitted sufficient information for the Secretary to
review the analysis under paragraph (2);
``(C) for each group health plan or health
insurance issuer that did submit sufficient information
under paragraph (2), the Secretary's conclusions as to
whether and why the plan or issuer is in compliance
with the requirements under this section;
``(D) the Secretary's specifications described in
paragraph (3) for each group health plan or health
insurance issuer that the Secretary determined did not
submit sufficient information for the Secretary to
review the analyses described in paragraph (1) for
compliance with this section; and
``(E) the actions the Secretary specifies under
paragraph (3)(A)(i) that each group health plan or
health insurance issuer that the Secretary determined
is not in compliance with this section is required take
to be in compliance with this section, including the
reason why the Secretary determined the plan or issuer
is not in compliance.
``(h) Notice.--Beginning with the second plan year beginning after
the date of enactment of the Helping to Optimize Patients' Experience
with Fertility Services Act, a group health plan and a health insurance
issuer offering group health insurance coverage shall provide notice to
participants and beneficiaries in such plan or coverage regarding the
coverage required by this section in accordance with regulations
promulgated by the Secretary.
``(i) Effective Date.--This section, and the amendments made by
this section, shall apply with respect to plan years beginning on or
after January 1, 2026.''.
(b) Enforcement.--Section 502 of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1132) is amended--
(1) in subsection (a)(6), by striking ``or (9)'' and
inserting ``(9), or (13)'';
(2) in subsection (b)(3), by striking ``subsection (c)(9)''
and inserting ``paragraphs (9) and (13) of subsection (c)'';
and
(3) in subsection (c), by adding at the end the following:
``(13)(A) The Secretary may assess a civil penalty against a health
insurance issuer for failing to provide coverage for infertility or
iatrogenic infertility treatments as required under section 714A, in an
amount up to $100 per day, beginning on the date on which the issuer
first denies such coverage and ending on the date on which the issuer
approves coverage, with respect to each participant or beneficiary
denied such coverage in violation of such section.
``(B) The Secretary may assess a civil penalty against a health
insurance issuer for failing to submit an analysis as required under
section 714A(g)(2), in an amount up to $100 for each day, beginning 45
days after the date on which the Secretary notifies such issuer that
the issuer is not in compliance with the requirement under section
714A(g)(2), and ending on the date on which the issue submits the
analysis as required.''.
(c) Conforming Amendment.--Section 731(c) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1191(c)) is amended
by striking ``section 711'' and inserting ``sections 711 and 714A''.
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