[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8821 Introduced in House (IH)]

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118th CONGRESS
  2d Session
                                H. R. 8821

    To ensure coverage for the treatment of infertility for certain 
                              conditions.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 25, 2024

 Mrs. Chavez-DeRemer (for herself, Mr. Nunn of Iowa, Ms. Wild, and Ms. 
Wasserman Schultz) introduced the following bill; which was referred to 
              the Committee on Education and the Workforce

_______________________________________________________________________

                                 A BILL


 
    To ensure coverage for the treatment of infertility for certain 
                              conditions.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Helping to Optimize Patients' 
Experience with Fertility Services Act'' or the ``HOPE with Fertility 
Services Act''.

SEC. 2. ENSURING BENEFITS FOR TREATMENT OF INFERTILITY AND IATROGENIC 
              INFERTILITY.

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et 
seq.) is amended by inserting after section 714 the following:

``SEC. 714A. STANDARDS RELATING TO BENEFITS FOR TREATMENT OF 
              INFERTILITY AND IATROGENIC INFERTILITY.

    ``(a) In General.--A group health plan or a health insurance issuer 
offering group health insurance coverage shall ensure that such plan or 
coverage provides coverage for infertility or iatrogenic infertility 
treatments, including--
            ``(1) the treatment of infertility, if such plan or 
        coverage provides coverage for obstetrical services; and
            ``(2) standard fertility preservation services when a 
        medically necessary treatment described in subparagraph (A), 
        (B), (C), or (D) of subsection (b)(1) causes, or is expected to 
        cause, iatrogenic infertility.
    ``(b) Definitions.--In this section:
            ``(1) Iatrogenic infertility.--The term `iatrogenic 
        infertility' means an impairment of fertility due to damage of 
        reproductive organs and processes resulting from--
                    ``(A) a surgical or other invasive medical 
                procedure as a result of an injury or life-threatening 
                illness, or involving a reproductive organ or process 
                in a manner likely to cause damage to such organ or 
                process;
                    ``(B) radiation therapy;
                    ``(C) chemotherapy; or
                    ``(D) myeloablative conditioning.
            ``(2) Infertility.--The term `infertility' means a disease 
        or condition characterized by--
                    ``(A) the inability to achieve spontaneous 
                pregnancy without medical treatment after a period of 
                at least 12 consecutive months of unprotected sexual 
                intercourse;
                    ``(B) the inability to achieve pregnancy after 
                receiving standard clinical treatment protocols under 
                the supervision of a treating physician who is a board-
                certified reproductive endocrinologist or obstetrician-
                gynecologist;
                    ``(C) being incapable of reproduction to live birth 
                based on medical and reproductive history, age, 
                physical findings or diagnostic testing of the 
                individual, as determined by a treating physician; or
                    ``(D) the inability to achieve spontaneous 
                pregnancy on account of a diagnosed condition that is a 
                disorder of ovulation, or a testicular or hormonal 
                disease or disorder.
            ``(3) Infertility or iatrogenic infertility treatment.--The 
        term `infertility or iatrogenic infertility treatment' means 
        treatments or procedures with the intent of facilitating a 
        pregnancy, including--
                    ``(A) such treatments or procedures that involve 
                the handling of human egg, sperm, and embryo outside of 
                the body, including in vitro fertilization and 
                maturation, egg and embryo cryopreservation, egg and 
                embryo donation, and intracytoplasmic sperm injection; 
                or
                    ``(B) such treatments or procedures that do not 
                involve the handling of human egg, sperm, and embryo 
                outside of the body, including ovulation induction, 
                genetic screening and diagnosis, sperm 
                cryopreservation, and intrauterine insemination.
    ``(c) Required Coverage.--A group health plan and a health 
insurance issuer offering group health insurance coverage that includes 
coverage for obstetrical services shall provide comprehensive coverage 
for infertility or iatrogenic infertility treatments, as determined by 
the Secretary in consultation with relevant stakeholders, provided to a 
participant or beneficiary if--
            ``(1) the participant or beneficiary has infertility, 
        including iatrogenic infertility; and
            ``(2) the treatment or service is performed at a medical 
        facility that is in compliance with standards set by 
        appropriate Federal and State agencies.
    ``(d) Financial Requirements and Treatment Requirements.--Any 
coverage provided by a group health plan or health insurance issuer in 
accordance with this section may be subject to coverage limits (such as 
medical necessity, pre-authorization, or pre-certification) and cost-
sharing requirements (such as coinsurance, copayments, and 
deductibles), as required under the group health plan or health 
insurance coverage, that are no more restrictive than the predominant 
coverage limits and cost-sharing requirements applied to substantially 
all medical and surgical benefits covered under the plan or coverage.
    ``(e) Prohibitions.--A group health plan and a health insurance 
issuer offering group health insurance coverage may not--
            ``(1) provide incentives (monetary or otherwise) to a 
        participant or beneficiary to encourage such participant or 
        beneficiary not to be provided infertility or iatrogenic 
        infertility treatments to which such participant or beneficiary 
        is entitled under this section, or to providers to induce such 
        providers not to provide such treatments to qualified 
        participants and beneficiaries;
            ``(2) prohibit a provider from discussing with a 
        participant or beneficiary infertility or iatrogenic 
        infertility treatments or medical treatment options required to 
        be covered under this section; or
            ``(3) penalize or otherwise reduce or limit the 
        reimbursement of a provider because such provider provided 
        infertility or iatrogenic infertility treatment services to a 
        participant or beneficiary in accordance with this section.
    ``(f) Rule of Construction.--Nothing in this section shall be 
construed to--
            ``(1) require a participant or beneficiary in a group 
        health plan or group health insurance coverage to undergo 
        infertility or iatrogenic infertility treatments;
            ``(2) impact the use by a group health plan or a health 
        insurance issuer offering group health insurance coverage of 
        utilization management tools; or
            ``(3) prevent a group health plan or a health insurance 
        issuer offering group health insurance coverage from 
        contracting with providers as to the level and type of 
        reimbursement with a provider for care provided in accordance 
        with this section.
    ``(g) Utilization Management Tools Requirements.--
            ``(1) In general.--In the case of a group health plan or a 
        health insurance issuer offering group health insurance 
        coverage that imposes utilization management tools on 
        infertility and iatrogenic infertility treatment benefits, for 
        the first 5 plan years that begin after the date of enactment 
        of the Helping to Optimize Patients' Experience with Fertility 
        Services Act, such plan or issuer shall perform and document 
        analyses of the design and application of the utilization 
        management tool such analysis and the following information:
                    ``(A) The specific plan or coverage terms or other 
                relevant terms regarding the utilization management 
                tools and a description of all infertility or 
                iatrogenic infertility treatment benefits, to which 
                each such term applies in each respective benefits 
                classification.
                    ``(B) The factors used to determine that the 
                utilization management tool will apply to infertility 
                or iatrogenic infertility treatment benefits.
                    ``(C) The evidentiary standards used for the 
                factors identified under subparagraph (B), when 
                applicable, provided that every factor shall be 
                defined, and any other source or evidence relied upon 
                to design and apply the utilization management tool to 
                infertility and iatrogenic infertility treatment 
                benefits.
                    ``(D) An analysis demonstrating that the processes, 
                strategies, evidentiary standards, and other factors 
                used to apply the utilization management tools to 
                infertility and iatrogenic infertility treatment 
                benefits as written and in operation, are consistent 
                with, and are applied no more stringently than with 
                clinical guidelines for infertility or iatrogenic 
                infertility treatments.
                    ``(E) The specific findings and conclusions reached 
                by the group health plan or health insurance issuer 
                with respect to the health insurance coverage, 
                including any results of the analyses described in this 
                paragraph that indicate that the plan or coverage is or 
                is not in compliance with this section.
            ``(2) Submission process.--
                    ``(A) Annual submission.--A group health plan or 
                health insurance issuer offering group health insurance 
                coverage shall submit to the Secretary the analyses 
                described in paragraph (1) annually for first 5 plan 
                years that begin after the date of enactment of the 
                Helping to Optimize Patients' Experience with Fertility 
                Services Act. For subsequent plan years, the Secretary 
                may request that a group health plan or a health 
                insurance issuer offering group health insurance 
                coverage submit the analysis described in paragraph (1) 
                in the case of potential violations of this section or 
                complaints regarding noncompliance with this section 
                that concern utilization management tools and any other 
                instances in which the Secretary determines 
                appropriate.
                    ``(B) Additional information.--If the Secretary 
                concludes that a group health plan or health insurance 
                issuer has not submitted sufficient information for the 
                Secretary to review the analysis described in paragraph 
                (1), the Secretary shall specify to the plan or issuer 
                the information the plan or issuer is required to 
                submit pursuant to subparagraph (A). Nothing in this 
                subparagraph shall require the Secretary to conclude 
                that a group health plan or health insurance issuer is 
                in compliance with this section solely based upon the 
                inspection of the analyses described in paragraph (1), 
                as requested under subparagraph (A).
            ``(3) Required action.--
                    ``(A) In general.--If, after review of the analyses 
                described in paragraph (1), the Secretary notifies the 
                group health plan or health insurance issuer that such 
                plan or issuer is not in compliance with this section, 
                the plan or issuer--
                            ``(i) shall specify to the Secretary the 
                        actions the plan or issuer will take to be in 
                        compliance with this section and provide to the 
                        Secretary additional analyses described in 
                        paragraph (1) that demonstrate compliance with 
                        this section not later than 45 days after the 
                        initial notification by the Secretary that the 
                        plan or issuer is not in compliance; and
                            ``(ii) following the 45-day corrective 
                        action period under clause (i), if the 
                        Secretary makes a final determination that the 
                        plan or issuer still is not in compliance with 
                        this section, not later than 7 days after such 
                        determination, shall notify all individuals 
                        enrolled in the applicable plan or health 
                        insurance coverage that such plan or coverage 
                        has been determined to be not in compliance 
                        with this section.
                    ``(B) Exemption from disclosure.--Documents or 
                communications produced in connection with the 
                Secretary's recommendations to a group health plan or 
                health insurance issuer shall not be subject to 
                disclosure pursuant to section 552 of title 5, United 
                States Code.
            ``(4) Report.--For plan years beginning on or after January 
        1, 2026, the Secretary shall submit to Congress, and make 
        publicly available, a report that contains--
                    ``(A) a summary of the analysis submitted under 
                paragraph (1), including the identity of each group 
                health plan or health insurance issuer offering health 
                insurance coverage that is determined to be not in 
                compliance after the final determination by the 
                Secretary described in paragraph (3)(A)(ii);
                    ``(B) the Secretary's conclusions as to whether 
                each group health plan or health insurance issuer 
                submitted sufficient information for the Secretary to 
                review the analysis under paragraph (2);
                    ``(C) for each group health plan or health 
                insurance issuer that did submit sufficient information 
                under paragraph (2), the Secretary's conclusions as to 
                whether and why the plan or issuer is in compliance 
                with the requirements under this section;
                    ``(D) the Secretary's specifications described in 
                paragraph (3) for each group health plan or health 
                insurance issuer that the Secretary determined did not 
                submit sufficient information for the Secretary to 
                review the analyses described in paragraph (1) for 
                compliance with this section; and
                    ``(E) the actions the Secretary specifies under 
                paragraph (3)(A)(i) that each group health plan or 
                health insurance issuer that the Secretary determined 
                is not in compliance with this section is required take 
                to be in compliance with this section, including the 
                reason why the Secretary determined the plan or issuer 
                is not in compliance.
    ``(h) Notice.--Beginning with the second plan year beginning after 
the date of enactment of the Helping to Optimize Patients' Experience 
with Fertility Services Act, a group health plan and a health insurance 
issuer offering group health insurance coverage shall provide notice to 
participants and beneficiaries in such plan or coverage regarding the 
coverage required by this section in accordance with regulations 
promulgated by the Secretary.
    ``(i) Effective Date.--This section, and the amendments made by 
this section, shall apply with respect to plan years beginning on or 
after January 1, 2026.''.
    (b) Enforcement.--Section 502 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1132) is amended--
            (1) in subsection (a)(6), by striking ``or (9)'' and 
        inserting ``(9), or (13)'';
            (2) in subsection (b)(3), by striking ``subsection (c)(9)'' 
        and inserting ``paragraphs (9) and (13) of subsection (c)''; 
        and
            (3) in subsection (c), by adding at the end the following:
    ``(13)(A) The Secretary may assess a civil penalty against a health 
insurance issuer for failing to provide coverage for infertility or 
iatrogenic infertility treatments as required under section 714A, in an 
amount up to $100 per day, beginning on the date on which the issuer 
first denies such coverage and ending on the date on which the issuer 
approves coverage, with respect to each participant or beneficiary 
denied such coverage in violation of such section.
    ``(B) The Secretary may assess a civil penalty against a health 
insurance issuer for failing to submit an analysis as required under 
section 714A(g)(2), in an amount up to $100 for each day, beginning 45 
days after the date on which the Secretary notifies such issuer that 
the issuer is not in compliance with the requirement under section 
714A(g)(2), and ending on the date on which the issue submits the 
analysis as required.''.
    (c) Conforming Amendment.--Section 731(c) of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1191(c)) is amended 
by striking ``section 711'' and inserting ``sections 711 and 714A''.
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