Revision of Bulletin 97-1: Basic Health Services and Infertility Services

BULLETIN NO. 2009-07 # REVISION OF BULLETIN 97-1: BASIC HEALTH SERVICES AND INFERTILITY SERVICES (Effective February 10, 2009) This bulletin addresses coverage of infertility services as a basic health care service under Chapter 1751 of the Revised Code. This bulletin is consistent with the standards promulgated by the United States Department of Health and Human Services, Health Care Financing Administration (HCFA), now known as Centers for Medicare and Medicaid Services, at 58 Federal Register 51632 for federally qualified health maintenance organizations. Basic health care services, as defined at section 1751.01(A) include the following services when medically necessary: (1) Physician services, except when such services are supplemental under division (B) of [that section]; (2) Inpatient hospital services; (3) Outpatient medical services; (4) Emergency health services; (5) Urgent care services; (6) Diagnostic laboratory services and diagnostic and therapeutic radiologic services; (7) Diagnostic and treatment services, other than prescription drug services, for biologically based mental illnesses; (8) Preventative health care services, including but not limited to, voluntary family planning services, infertility services, periodic physical examinations, prenatal obstetrical care, and well-child care (emphasis added); (9) Routine patient care for patients enrolled in an eligible cancer clinical trial pursuant to section 3923.80 of the Revised Code. Although infertility services are referenced, such services are subject to the general qualification that they be medically necessary. The department interprets basic health care services with regard to infertility services to mean diagnostic and exploratory procedures to determine infertility including surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs including but not limited to, endometriosis, collapsed/clogged fallopian tubes or testicular failure. Procedures such as in vitro fertilization ("IVF"), gamete intrafallopian transfer ("GIFT") and zygote intrafallopian transfer ("ZIFT") are not essential for the protection of an individual's health and are therefore not mandated benefits as basic health care services. This does not preclude coverage for these services; it merely states that coverage for these services is not mandatory by law. Mary Jo Hudson Mary Jo Hudson Superintendent of Insurance