Fertility Benefits as Excepted Benefits under the ACA - The Impact on Plan Sponsors and Participants

A May 2026 proposed rule titled Excepted Fertility Benefits introduces a new category of limited excepted benefits under the Affordable Care Act (ACA). This rule aims to establish certain fertility benefits as separate from traditional group health plans, potentially improving the ability of employers to provide group health plan participants with access to, and the ability to better manage fertility-related care.

What Are Excepted Benefits under the ACA?

The ACA imposes certain rules on the type of benefits that can be offered under employer-sponsored group health plans. These rules include limits on the amount a plan participant is required to pay for certain medical plan benefits.

Excepted benefits are specific categories of medical plan benefits that are exempt from these ACA requirements, which means they can be offered as a stand-alone benefit, or alongside traditional group health plans without triggering an obligation to comply with comprehensive ACA regulations on cost-sharing and coverage limits.

Under a new proposed rule issued by the DOL in May 2026, fertility benefits could also be categorized as an excepted benefit, allowing employers to offer fertility coverage separately from their main health plans without having to comply with cost-sharing and coverage limits

Key Elements of the Proposed Excepted Fertility Benefits Rule

The proposed rule, if made final, would re-define fertility benefits narrowly to include services related to diagnosis and treatment of infertility, such as:

• Fertility preservation procedures

• Assisted reproductive technologies (ART), including in vitro fertilization (IVF)

• Counseling and diagnostic testing related to fertility

  
  

The proposed rule still excludes broader reproductive health services like contraception or pregnancy care, focusing specifically on infertility treatment.

Eligibility and Coverage Limits

Employers would have more flexibility in designing fertility benefit packages, including setting limits on:

• Number of treatment cycles covered

• Dollar caps on benefits

• Types of services included

  
  

This flexibility allows employers to tailor fertility benefits to their workforce needs and budget constraints.

Impact on Employers Sponsoring Group Health Plans

Employers face several implications from this proposed rule:

1. Plan Design Flexibility

Employers can offer fertility benefits as stand-alone coverage or as an add-on to existing plans without triggering ACA compliance issues for the entire health plan. This flexibility helps employers:

• Control costs by limiting fertility benefit scope

• Provide targeted support for employees seeking fertility care

• Avoid complex ACA mandates that apply to full health plans

  
  

2. Administrative Considerations

The proposed rule has other implications. For example, offering fertility benefits separately may require employers to:

• Work with new vendors or insurers specializing in fertility coverage

• Communicate clearly with employees about the differences between fertility benefits and main health plans

• Manage enrollment and claims processes for separate benefits

  
  

3. Potential Cost Implications

Fertility treatments can be expensive. By offering limited excepted benefits, employers might:

• Reduce overall health plan costs by capping fertility coverage

• Shift some financial responsibility to employees through separate premiums or cost-sharing

  
  

Employers should weigh these factors carefully to balance affordability and employee satisfaction.

Impact on Plan Participants

Employees and their dependents may experience changes in how they access fertility care:

1. Separate Enrollment and Coverage

Fertility benefits offered as excepted benefits may require separate enrollment. Participants should understand:

• How to enroll in fertility benefits

• What services are covered and any limits

• Differences in cost-sharing compared to their main health plan

  
  

2. Potential for Limited Coverage

Because employers can limit fertility benefits, participants might face:

• Caps on the number of treatment cycles covered

• Dollar limits that may not cover all expenses

• Exclusions of certain fertility services

  
  

Participants should review plan documents carefully to understand their coverage.

3. Access to Specialized Care

On the positive side, fertility benefits as excepted benefits could improve access by:

• Offering focused coverage designed specifically for infertility treatment

• Providing access to fertility specialists and services not always covered under general health plans

  
  

Examples of How Employers Might Use Excepted Fertility Benefits

• A mid-sized company offers a separate fertility benefit plan covering up to three IVF cycles with a $30,000 lifetime maximum, separate from the main health plan.

• A large employer partners with a fertility benefits vendor to provide counseling and diagnostic testing as a limited excepted benefit, while the main health plan covers pregnancy and childbirth.

• A small business offers fertility preservation coverage for employees undergoing medical treatments that risk infertility, as a stand-alone excepted benefit.

  
  

These examples show how employers can customize fertility benefits to meet workforce needs while managing costs.

Considerations for Employers and Participants

For Employers

• Review current fertility coverage and assess if offering excepted fertility benefits aligns with company goals.

• Communicate clearly with employees about changes to fertility benefits and enrollment procedures.

• Monitor regulatory updates as the proposed rule moves through the rulemaking process.

  
  

For Participants

• Understand the scope and limits of fertility benefits offered.

• Ask questions about enrollment deadlines, covered services, and out-of-pocket costs.

• Consider supplemental insurance or other financial resources if fertility benefits are limited.

  
  
  
  

The proposed Excepted Fertility Benefits rule represents a significant shift in how fertility care can be offered alongside group health plans. Employers gain flexibility to design targeted fertility benefits, while participants may see changes in coverage structure and limits. Staying informed and proactive will help both employers and employees navigate these changes effectively.

For those interested in fertility benefits, now is a good time to review current plans and prepare for potential updates in 2026.