The state of Illinois is among the best states for addressing infertility. The state has a mandate to cover healthcare services for the diagnosis of infertility as well as treatments and procedures that help couples and individuals achieve pregnancy. This includes up to four egg retrievals for in vitro fertilization (IVF).
Does the state of Illinois have a fertility coverage mandate?
Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to the following: diagnosis of infertility; IVF; uterine embryo lavage; embryo transfer; artificial insemination; GIFT; ZIFT; low tubal ovum transfer. Coverage for IVF, GIFT and ZIFT is provided if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, infertility treatments covered by insurance.
Each patient is covered for up to 4 egg retrievals. However, if a live birth occurs, two additional egg retrievals will be covered, with a lifetime maximum of six retrievals covered. The procedures must be performed at facilities that conform with ACOG and ASRM guidelines.
An individual or group policy of accident and health insurance must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee.
What is the scope of the mandate?
Only applies to group health policies offering pregnancy related benefits and covering more than 25 employees.
Are there requirements or limitations on coverage?
Procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer must be covered only if:
- The covered individual has been unable to attain or maintain a viable pregnancy, or have a successful pregnancy, through less costly medically appropriate infertility treatment that the plan covers; and
- The covered individual has not already undergone four completed oocyte retrievals. (except: if a live birth follows a completed oocyte retrieval, then two more oocyte retrievals shall be covered); and
- The procedures are performed at medical centers which conform to standards for in vitro fertilization clinics/programs set by the American College of Obstetric and Gynecology or the American Fertility Society
215 Ill. Comp. Stat. 5/356m(b) (2016).
Are there exemptions to the mandate?
Employers with fewer than 25 employees do not have to provide coverage. The mandate does not require religious employers to cover infertility treatment.
Employers who self-insure are exempt from the requirements of the law. If HHS requires the State, pursuant to the ACA, to defray the cost of fertility preservation coverage, then fertility preservation coverage is no longer operative.
Is fertility preservation covered under the mandate?
The coverage mandate applies to individual or group health or accident insurance policy amended, delivered, issued, or renewed in Illinois after Jan. 1, 2019.
These plans must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical service may directly or indirectly cause iatrogenic infertility to an enrollee.
“Standard fertility preservation services” means procedures based upon current evidence-based standards of care developed by national medical associations that follow evidence-based standards of care (American Society for Reproductive Medicine, American Society of Clinical Oncology, etc.)
“Iatrogenic infertility” means an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. 215 Ill. Comp. Stat. 5/356z.32 (2019).