HOPE with Fertility Services Act

This provision mandates that group health plans and health insurance issuers offering group health insurance coverage, if they cover obstetrical services, must also provide coverage for infertility treatments. It further requires coverage for standard fertility preservation services when a medically necessary treatment (such as chemotherapy or radiation therapy) is expected to cause iatrogenic infertility.

This section provides detailed definitions for 'iatrogenic infertility' (fertility impairment due to damage from medical procedures like surgery, radiation, chemotherapy, or myeloablative conditioning) and 'infertility' (inability to achieve pregnancy after 12 months, or after standard treatment, or based on medical history/testing, or due to specific diagnosed conditions). It also defines 'infertility or iatrogenic infertility treatment' to include both in-vitro procedures (e.g., IVF, egg/embryo cryopreservation) and non-in-vitro procedures (e.g., ovulation induction, genetic screening, sperm cryopreservation, IUI).

This provision stipulates that any coverage provided for infertility or iatrogenic infertility treatments must be subject to coverage limits (such as medical necessity, pre-authorization, or pre-certification) and cost-sharing requirements (such as coinsurance, copayments, and deductibles) that are no more restrictive than those applied to substantially all medical and surgical benefits covered under the same plan or coverage.

This section prohibits group health plans and issuers from offering incentives (monetary or otherwise) to discourage participants from receiving fertility treatments to which they are entitled. It also forbids plans from preventing providers from discussing treatment options with patients or from penalizing providers for offering infertility or iatrogenic infertility treatment services in accordance with the Act.

For the first five plan years after enactment, health plans must perform and document detailed analyses of their utilization management tools for fertility treatments. These analyses must demonstrate consistency with clinical guidelines and non-stringent application compared to other medical benefits, and be submitted annually to the Secretary. The Secretary can request further information, and if non-compliance is found, require corrective actions and public notification to enrollees. A public report to Congress summarizing findings is also mandated annually.

This section amends ERISA to allow the Secretary to assess civil penalties against health insurance issuers for non-compliance. Penalties can be up to $100 per day for each participant or beneficiary denied required coverage, starting from the denial date until approval. Additionally, a penalty of up to $100 per day can be assessed for failing to submit required utilization management analyses, starting 45 days after notification of non-compliance and ending when the analysis is submitted.