As many as 20% of patients will have coverage for infertility services designated as diagnostic only. This means that only testing will be covered, but not treatment. In these patients, it is very important to do all testing first before any treatment is started, such as ovulation induction with clomiphene citrate. After treatment has started, no further testing will be covered. With diagnostic only coverage, the patient is considered self-pay for all infertility treatment.
Illinois is one of 8 states which have state-mandated coverage for IVF. If a patient has state mandated coverage, she must first meet the definition of infertility which is one year of unprotected intercourse in a women age 35.
Although Illinois has this designation, if a patient is employed by a company with main headquarters located outside of Illinois or if the company is self-insured or has less than 25 employees, they are exempt from the state mandate. Additionally, health insurance provided by the federal government is not subject to state mandates. This includes TRICARE for the military, Veterans Administration benefits, Medicaid and Medicare, and the insurance plan for federal employees.
Barbara Collura, President/CEO, RESOLVE: The National Infertility Association has provided updated information on changes in the Illinois State Mandate as of January 1, 2016. The Illinois state legislature approved what might appear to be subtle changes to the existing IVF mandate, but in fact may help more people access the mandate.
Old Definition of Infertility in the Illinois IVF mandate: Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
New Definition of Infertility in the Illinois IVF mandate: Infertility means the inability to conceive after one year of unprotected sexual intercourse, the inability to conceive after one year of attempts to produce conception, the inability to conceive after an individual is diagnosed with a condition affecting fertility, or the inability to sustain a successful pregnancy.
The impact to the patient is that they no longer have to try to conceive by having sexual intercourse. This could open up the mandate to single women and same sex couples. It still remains to be seen how the insurance companies now implement this change.
Also, it could mean that people that have had cancer or another condition affecting their fertility, that they could now access the IVF mandate. It is clear, however, that the definition was broadened and allows more opportunity for those wishing for a family to actually access the IVF mandate and have their insurance cover it.