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1H.55
2 Introduced by Representatives Headrick of Burlington, Burrows of West
3Windsor, Casey of Montpelier, Cina of Burlington, Cole of
4Hartford, Logan of Burlington, McCann of Montpelier, McGill
5of Bridport, Priestley of Bradford, Surprenant of Barnard,
6Tomlinson of Winooski, and Waszazak of Barre City
7 Referred to Committee on
8 Date:
9 Subject: Health; health insurance; gender-affirming care; fertility treatment
10 Statement of purpose of bill as introduced: This bill proposes to expand access
11 to health insurance coverage for gender-affirming health care services. It
12 would also require health insurance plans and Vermont Medicaid to provide
13 coverage for fertility-related services and direct the Agency of Human Services
14 to seek federal approval of an amendment to Vermont’s Medicaid state plan to
15 permit the Medicaid coverage.
16    An act relating to coverage for fertility treatment and gender-affirming
17    health care services
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1 It is hereby enacted by the General Assembly of the State of Vermont:
2 Sec. 1. 8 V.S.A. § 4088m is amended to read:
3 § 4088m. COVERAGE FOR GENDER-AFFIRMING HEALTH CARE
4SERVICES
5    (a) Definitions. As used in this section:
6(1) “Gender-affirming health care services” has the same meaning as in
7 1 V.S.A. § 150.
8(2) “Health care provider” has the same meaning as in 18 V.S.A.
9 § 9402.
10(3) “Health insurance plan” means Medicaid and any other public health
11 care assistance program, any individual or group health insurance policy, any
12 hospital or medical service corporation or health maintenance organization
13 subscriber contract, or any other health benefit plan offered, issued, or renewed
14 for any person in this State by a health insurer as defined by 18 V.S.A. § 9402.
15 For purposes of this section, health insurance plan includes any health benefit
16 plan offered or administered by the State or any subdivision or instrumentality
17 of the State. The term does not include benefit plans providing coverage for a
18 specific disease or other limited benefit coverage, except that it includes any
19 accident and sickness health plan.
20    (b) Coverage.
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1(1)(A) A health insurance plan shall provide coverage for gender-
2 affirming health care services that:
3(A) are medically necessary and clinically appropriate for the
4 individual’s diagnosis or health condition; and, as determined by the covered
5 individual’s treatment health care provider. Medically necessary gender-
6 affirming health care services shall include, if determined by the treating health
7 care provider to be clinically appropriate for a covered individual:
8(i) facial masculinization and feminization procedures; and
9(ii) facial hair removal, such as laser hair removal or electrolysis.
10(B) are included in the State’s essential health benefits benchmark
11 plan A health insurance plan shall not impose barriers to accessing gender-
12 affirming health care services, such as mandating a specific duration of
13 hormone therapy or requiring correspondence from more than one health care
14 provider before authorizing gender-affirming surgery or other gender-affirming
15 health care services.
16(2) Coverage provided pursuant to this section by Medicaid or any other
17 public health care assistance program shall comply with all federal
18 requirements imposed by the Centers for Medicare and Medicaid Services.
19(3) Nothing in this section shall prohibit a health insurance plan from
20 providing greater coverage for gender-affirming health care services than is
21 required under this section.
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1    (c) Cost sharing. A health insurance plan shall not impose greater
2 coinsurance, co-payment, deductible, or other cost-sharing requirements for
3 coverage of gender-affirming health care services than apply to the diagnosis
4 and treatment of any other physical or mental condition under the plan.
5    (d) On or before January 15 of each year, the Department of Financial
6 Regulation shall report to the House Committee on Health Care and the Senate
7 Committees on Health and Welfare and on Finance on health insurance plans’
8 compliance with this section, utilization of gender-affirming health care
9 services during the previous calendar year, and any identified barriers to access
10 to care.
11 Sec. 2. 8 V.S.A. § 4099f is added to read:
12 § 4099f. FERTILITY-RELATED SERVICES
13    (a) Definitions. As used in this section:
14(1) “Experimental fertility procedure” means a procedure for which the
15 published medical evidence is not sufficient for the American Society for
16 Reproductive Medicine, its successor organization, or a comparable
17 organization to regard the procedure as established medical practice.
18(2) “Fertility diagnostic care” means procedures, products, medications,
19 and services intended to provide information about an individual’s fertility,
20 including laboratory assessments and imaging studies.
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1(3) “Fertility preservation services” means procedures, products,
2 medications, and services intended to preserve fertility, consistent with
3 established medical practice and professional guidelines published by the
4 American Society for Reproductive Medicine, its successor organization, or a
5 comparable organization, for an individual who has a medical or genetic
6 condition or who is expected to undergo treatment that may directly or
7 indirectly cause a risk of impairment of fertility. “Fertility preservation
8 services” includes the procurement and cryopreservation of gametes, embryos,
9 and reproductive material and storage from the time of cryopreservation for a
10 period of five years. Storage may be offered for a longer period of time.
11(4) “Health care provider” has the same meaning as in 18 V.S.A.
12 § 9402.
13(5) “Health insurance plan” means any individual or group health
14 insurance policy; any hospital or medical service corporation or health
15 maintenance organization subscriber contract; or any other health benefit plan
16 offered, issued, or renewed for any person in this State by a health insurer.
17 The term does not include benefit plans providing coverage for specific
18 diseases or other limited benefit coverage.
19(6) “Health insurer” has the same meaning as in 18 V.S.A. § 9402.
20    (b) Required coverage. A health insurance plan shall provide coverage for
21 the following fertility-related services for all insureds:
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1(1) Fertility diagnostic care.
2(2) Intrauterine insemination treatment with donor or partner semen.
3(3) At least three retrievals of oocytes under anesthesia for in vitro
4 fertilization (IVF) with donor or partner semen or egg, including appropriate
5 medications for ovarian stimulation; unlimited embryo transfers; and IVF-
6 related laboratory procedures, ultrasounds, and hormones. A health insurance
7 plan may, but shall not be required to, provide coverage for preimplantation
8 genetic testing as a component of IVF.
9(4) Clinically appropriate fertility-related medications as ordered or
10 prescribed by the insured’s treating health care providers.
11(5) Fertility preservation services.
12    (c) Access to services; limitations on coverage.
13(1) A health insurance plan shall not establish any rate, term, or
14 condition that places a greater financial burden on an insured for access to
15 fertility-related services than for access to treatment for any other health
16 condition.
17(2) A health insurance plan shall not impose any limitations on coverage
18 for any fertility services based on an insured’s use of donor sperm or eggs,
19 donor embryos, or surrogacy.
20(3) A health insurance plan is not required to provide coverage for:
21(A) any experimental fertility procedure; or
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1(B) any nonmedical costs related to donor sperm or eggs, donor
2 embryos, or surrogacy.
3    (d) Reporting. On or before January 15 of each year, the Department of
4 Financial Regulation shall report to the House Committee on Health Care and
5 the Senate Committees on Health and Welfare and on Finance on health
6 insurance plans’ compliance with this section, utilization of fertility-related
7 services during the previous calendar year, and any identified barriers to access
8 to care.
9 Sec. 3. 33 V.S.A. § 1901n is added to read:
10 § 1901n. COVERAGE OF FERTILITY-RELATED SERVICES
11    (a) Definitions. As used in this section:
12(1) “Fertility diagnostic care” and “fertility preservation services” have
13 the same meanings as in 8 V.S.A. § 4099f.
14(2) “Health care provider” has the same meaning as in 18 V.S.A.
15 § 9402.
16    (b) Coverage. The Agency of Human Services shall provide Medicaid
17 coverage for the following fertility-related services for all Medicaid
18 beneficiaries:
19(1) Fertility diagnostic care.
20(2) Intrauterine insemination treatment with donor or partner semen.
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1(3) At least three retrievals of oocytes under anesthesia for in vitro
2 fertilization (IVF) with donor or partner semen or egg, including appropriate
3 medications for ovarian stimulation; unlimited embryo transfers; and IVF-
4 related laboratory procedures, ultrasounds, and hormones. The Agency may,
5 but shall not be required to, provide Medicaid coverage for preimplantation
6 genetic testing as a component of IVF.
7(4) Clinically appropriate fertility-related medications as ordered or
8 prescribed by the beneficiary’s treating health care providers.
9(5) Fertility preservation services.
10 Sec. 4. COVERAGE FOR FERTILITY-RELATED SERVICES; MEDICAID
11STATE PLAN AMENDMENT
12    On or before September 1, 2025, the Agency of Human Services shall
13 request approval from the Centers for Medicare and Medicaid Services to
14 amend Vermont’s Medicaid state plan to include coverage for fertility-related
15 services as set forth in Sec. 3 of this act.
16 Sec. 5. EFFECTIVE DATES
17    (a) Secs. 1 (8 V.S.A. § 4088m) and 2 (8 V.S.A. § 4099f) shall take effect
18 on January 1, 2026 and shall apply to all health insurance plans issued on and
19 after January 1, 2026 on such date as a health insurer offers, issues, or renews
20 the health insurance plan, but in no event later than January 1, 2027.
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1    (b) Sec. 3 (33 V.S.A. § 1901n) shall take effect upon approval by the
2 Centers for Medicare and Medicaid Services of Vermont’s request to provide
3 coverage of fertility-related services as set forth in that section.
4    (c) Sec. 4 (coverage for fertility-related services; Medicaid state plan
5 amendment) and this section shall take effect on passage.
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