STANDARDS FOR FERTILITY COVERAGE - Chapter 865 - Coverage requirements and definitions

Sep 1, 2026

Rule implementation for fertility care coverage sets authority under Maine statutory provisions and establishes how carriers must administer fertility-related benefits. It specifies coverage applicability to policies, contracts, riders, and endorsements delivered or renewed in the State on or after January 1, 2025, and addresses certain claims tied to 2024 coverage. The rule defines key fertility terms, including assisted hatching, cryopreservation, embryo transfer, and multiple reproductive procedures, and requires nondiscriminatory access and adoption of at-least-equivalent clinical guidelines.

LanguageEnglish

CategoryForms

FormatDOCX

Pages8

Reading Time3 min

AccessFree to download

Authority and Purpose

Applicability and Scope

Definitions

Coverage Requirements

Required Benefits

Permissible Benefit Limitations and Exclusions

Benefit Mandate Defrayal

Severability

Effective Date

02 DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION 031 BUREAU OF INSURANCE Chapter 865: STANDARDS FOR FERTILITY COVERAGE TABLE OF CONTENTS Section 1. Authority and Purpose Section 2. Applicability and Scope Section 3. Definitions Section 4. Coverage Requirements Section 5. Required Benefits Section 6. Permissible Benefit Limitations and Exclusions Section 7. Benefit Mandate Defrayal Section 8. Severability Section 9. Effective Date Section 1. Authority and Purpose The Superintendent adopts this rule pursuant to 24-A M.R.S. §§ 212 and 4320-U(5) to implement the fertility care coverage requirements of 24-A M.R.S. § 4320-U. Section 2. Applicability and Scope This rule applies to all policies, contracts, riders, and endorsements delivered, issued, executed or renewed in this State on and after January 1, 2025 by a carrier as defined in this rule. Section 7 also applies to claims paid under coverage issued or renewed in 2024. Section 3. Definitions 1. “Assisted hatching” means a micromanipulation technique in which a hole is artificially created in the outer shell of an embryo to assist with the potential implantation of that embryo. 2. “Carrier” has the same meaning as defined in 24-A M.R.S. §4302-A(1)(3). 3 “Cryopreservation” means the freezing of embryos, eggs, sperm, ovarian tissue, or testicular tissue. 4. “Egg retrieval” means a procedure by which eggs are collected from ovarian follicles, including all office visits, procedures, and laboratory and radiological tests performed in preparation for egg retrieval; the attempted or successful retrieval of the egg(s); and, if the retrieval is successful, culture and fertilization of the egg(s). 5. “Embryo” means a cell or group of cells that has the potential to develop into a live born human being if transferred into the body under conditions in which gestation may be reasonably expected to occur. 6. “Embryo transfer” means the placement of an embryo into the uterus or fallopian tube. 7. “Experimental fertility procedure” has the same meaning as defined in 24-A M.R.S. § 4320-U(1)(A). 8. “Federal Affordable Care Act” has the same meaning as defined in 24-A M.R.S. § 14. 9. “Fertility coverage” means coverage provided by a carrier for fertility diagnostic care, fertility preservation services, and fertility treatment. 10. “Fertility diagnostic care” has the same meaning as defined in 24-A M.R.S. § 4320U(1)(B). 11 “Fertility patient” has the same meaning as defined in 24-A M.R.S. § 4320-U(1)(C). 12. “Fertility preservation services” has the same meaning as defined in 24-A M.R.S. § 4320U(1)(D). 13. “Fertility treatment” has the same meaning as defined in 24-A M.R.S. § 4320-U(1)(E). 14. “Fertilization” means the penetration of the egg by the sperm. 15. “Gamete intrafallopian tube transfer” means the direct transfer of a sperm/egg mixture into the fallopian tube by laparoscopy. 16. “Gestational carrier” means a person who carries an embryo that was not formed from the gestational carrier’s own egg, and who intends that a fertility patient, and not the gestational carrier, will be a parent of the child after birth. 17. “Iatrogenic infertility” means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. 18. “Infertility” has the same meaning as defined in 24-A M.R.S. § 4320-U(1)(G). 19. “Intracytoplasmic sperm injection” means a micromanipulation procedure whereby a single sperm is injected into the center of an egg. 20. “Intrauterine or vaginal insemination” means the introduction of sperm into the uterus, cervix, or vagina by noncoital methods for the purpose of conception. 21. “In vitro fertilization” means an assisted reproductive technology procedure whereby eggs are removed from the ovaries and fertilized outside the body. The resulting embryo is then transferred into the uterus. 22. “Maine Health Insurance Marketplace” has the same meaning as defined in 22 M.R.S. § 5403. 23. “Microsurgic

FAQs

What authority and purpose does the rule establish for fertility coverage?

The Superintendent adopts the rule to implement fertility care coverage requirements under Maine law cited in the rule's authority section.

When does the fertility coverage rule apply to insurance policies?

It applies to policies, contracts, riders, and endorsements delivered, issued, executed, or renewed in the State on or after January 1, 2025, with Section 7 also applying to certain claims paid under coverage issued or renewed in 2024.

What kinds of terms are defined in the rule?

The rule defines terms such as assisted hatching, cryopreservation, egg retrieval, embryo and embryo transfer, fertility diagnostic care, fertility preservation services, and fertility treatment, along with several specific assisted reproductive procedures.

Sep 1, 2026

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