Illinois
Coverage Mandate 1:
Yes.
Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to: 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.
Group insurers and HMOs that provide pregnancy related coverage must provide infertility treatment including, but not limited to: 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.
Scope of Mandate 2:
Only applies to group health policies offering pregnancy related benefits and covering more than 25 employees.
Coverage Cap 3:
N/A
Requirements or Limitations on Coverage 4:
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).
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).
Exemptions 5:
Employers with fewer than 25 employees do not have to provide coverage.
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.
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.
Fertility Preservation:
Yes.
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).
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).
Notes
1 Does the state have a coverage mandate, Y/N. Include effective date of the mandate. Specify if the mandate is to “offer” services or to “cover” them.
2Which insurers are required to comply with the mandate. If not applicable, put N/A.
3Is there a cap (annual/lifetime)?
4Does the law impose age restrictions on eligibility for coverage? Does it limit the number of IVF cycles covered (or require at least a certain number of services be covered)? Does it mandate a waiting period? Other limitations? How is “infertility” defined? Is it inclusive (e.g.: does it apply only to married or -opposite sex couples, or is it inclusive?)
5What, if any, exemptions apply to coverage under the mandate? For example: an exemption for small businesses or religious organizations.
Resources For You
The American Society for Reproductive Medicine (ASRM) is committed to providing patients with the highest quality information about reproductive care.
