Health Plan’s Infertility Benefit: Obtaining a Diagnosis of Infertility – What Is and Is Not Covered
In recognition of the challenges faced by many of our participants pursuing parenthood, the Directors Guild of America-Producer Health Plan began offering infertility benefits –managed by Carrot– to qualifying covered participants and dependent spouses effective July 1, 2022 for medically necessary infertility treatment based upon a medical diagnosis of infertility.
Any participant or dependent spouse, including same-sex spouses and gender diverse spouses, with a diagnosis of infertility from their provider is eligible for the $30,000 lifetime benefit, provided they are covered under Earned Active, Earned Inactive, Regular Carry-over, or related COBRA Continuation coverage with the Health Plan.[1]
Obtaining a Diagnosis of Infertility
Neither Carrot nor the Health Plan make the diagnosis of infertility. Only your provider can provide you with this diagnosis.
Medical providers can determine infertility based on any generally accepted medical guidelines. While the Centers for Disease Control (CDC) guidelines state that in general, infertility is defined as not being able to get pregnant after at least one year of unprotected sex, providers can make the diagnosis based on any number of guidelines, including, but not limited to, those issued by the American Society of Reproductive Medicine (ASRM). Unlike the CDC guidelines, the ASRM recently updated its guidelines to define infertility as a disease, condition, or status including the following:
- The inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.
- The need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner.
Regardless of which guideline is used, if you or your spouse has a medical diagnosis of infertility from your provider, you are eligible for the $30,000 lifetime benefit for family forming ($60,000 if both of you are diagnosed with infertility).
Infertility Benefits Not Covered by Carrot
In order for the Health Plan to provide medical benefits to you on a non-taxable basis, the benefit must be a reimbursement for “qualifying medical expenses” (QMEs) as defined in Internal Revenue Code Section 213(d).
The definition of QMEs is complicated, but under the IRS rules, QMEs do not include fertility benefits, including in vitro fertilization not performed on you or your eligible spouse, or expenses incurred by donors or gestational surrogates.
In addition, only services provided by Carrot’s in-network providers are covered. Any treatment received from a provider not included in the Carrot network is not covered by the Health Plan.
Learn More
To learn more about the Health Plan’s infertility benefits through Carrot, visit www.dgaplans.org/infertilitybenefits
[1] This excludes participants and spouses on Extended Self-Pay coverage, Retiree coverage, or any other Self-Pay coverage.
