Ohio Miscellaneous Regulatory Material DEPARTMENT OF INSURANCE BULLETINS Bulletin 97-1 Basic health services and infertility services	Effective Date November 13, 1997

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) 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;

(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) 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).

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.

Harold T. Duryee
Superintendent of Insurance

DATE NEW 1997

SUBJECT CATEGORY 060 - Health insurance / insurers
065 - Health service corporations
300 - The policy
320 - Mandated health benefits

INDEX
Infertility coverage and Health insurance and Policy provisions
Benefit limitations and Infertility coverage and Health insurance