Insurance Coverage in Illinois for Infertility Treatment
Infertility is a condition that strikes hundreds of couples in Illinois. Illinois law requires group insurance plans and health maintenance organizations (HMOs) to provide coverage for infertility. Here are the basic facts about the law.
Who Must Offer the Coverage?
Illinois law requires insurance companies and HMOs to provide coverage for infertility to employee groups of more than 25. The law does not apply to self-insured employers or to trusts or insurance policies written outside Illinois. However, for HMOs, the law does apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois. To determine if your HMO provides infertility benefits, you should contact the HMO directly or check your certificate of coverage.
Who is Covered?
To receive infertility coverage, you must:
- live in Illinois
- be covered by a fully insured Illinois group policy through an employer with more than 25 full-time employees
- have been unable to conceive after one year of unprotected sexual intercourse between a male and female or have been unable to sustain a successful pregnancy
What is Covered?
Illinois requires group insurance and HMO plans to cover the diagnosis and treatment of infertility the same as all other conditions. For example, they may not apply any unique co-payments or deductibles for infertility coverage. Benefits shall include, but not be limited to:
- testing
- prescription drugs
- artificial insemination
- invitro fertilization (IVF)
- gamete intrafallopian tube transfer (GIFT)
- intracytoplasmic sperm injection (ICSI)
- donor sperm and eggs (medical costs)
- procedures utilized to retrieve oocytes or sperm and subsequent procedures used to transfer the oocytes or sperm to the covered recipient are covered
What are the Limits?
Benefits for advanced procedures such as IVF, GIFT, ZIFT or ICSI are required only if you have been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy.
The benefits for advanced procedures required by the law are four completed oocyte retrievals per lifetime of the individual, except that two completed oocyte retrievals are covered after a successful live birth is achieved as a result of an artificial reproductive transfer of oocytes. For example, if a successful live birth takes place as a result of the first completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of three are covered under the law. If a live birth takes place as a result of the fourth completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of six are covered. The maximum number of completed oocyte retrievals that can be covered under the law is six.
One completed oocyte retrieval could result in many IVF, GIFT, ZIFT or ICSI procedures. There is no limit on the number of procedures, including less invasive procedures such as artificial insemination. The only limitations are on the number of completed oocyte retrievals.
NOTE: Once the final covered oocyte retrieval is completed, one subsequent procedure (IVF, GIFT, ZIFT, or ICSI) used to transer the oocytes or sperm is covered. After that, the benefit is maxed out and no further benefits are available under the law.
NOTE: Oocyte retrievals are per lifetime of the individual. If you had a completed oocyte retrieval in the past that was paid for by another carrier, or not covered by insurance, it still counts toward your lifetime maximum under the law.
What is Not Covered?
Your group insurance or HMO plan does not have to pay for:
- costs incurred for reversing a tubal ligation or vasectomy
- costs for services rendered to a surrogate, however, costs for procedures to obtain eggs, sperm or embryos from a covered individual shall be covered if the individual chooses to use a surrogate and if the individual has not exhausted benefits for completed oocytes retrievals
- costs of preserving and storing sperm, eggs and embryos
- costs for an egg or sperm donor which are not medically necessary; any fees for non-medical services paid to the donor are not covered under the law
- experimental treatments
- costs for procedures which violate the religious and moral teachings or beliefs of the insurance company or covered group
