Illinois infertility and IVF health insurance is mandated by state law. The law mandates that insurers must provide coverage to employer groups with 25 or more employees.
But the law has limitations, and not all Illinois residents and workers are covered.
When investigating laws, look beyond infertility procedures to the resulting pregnancy and maternity leave. Illinois laws do not replace mom’s income, an important consideration for couples trying to conceive – no matter what your insurance plan pays for your infertility or IVF procedures. Discover:
- Who the law applies to
- What procedures are covered
- Where the limitations are – and how to get unlimited IVF
- Deductible infertility expenses
Illinois Groups Subject to Mandate
The Illinois infertility insurance law applies to employers with more than 25 employees. The mandate does not apply to trusts, groups that self insure, group policies issued in another state, or religious organizations.
Many larger employers (those with one thousand or more employees) self insure which leaves them free to ignore the requirements. IL couples who are trying to conceive have the greatest odds of having coverage for infertility if they work for medium sized employers: those with more than 25 but employees, but not so big they self insure.
If your employer is headquartered in another state, your employer is not subject to the Illinois rules; it must comply to that state’s infertility mandate. Most states do have laws mandating infertility services, and those that do have less comprehensive requirements. You may be out of luck if this describes your situation.
Health Maintenance Organizations (HMO) may be required to follow the mandate if the HMO maintains a provider network in the state of Illinois.
Religious organizations are exempt from the requirement if a procedure violates the moral teachings or belief of the group. This exception may extend to subsidiaries and affiliated entities. Make sure you verify coverage before beginning any treatments for your infertility.
Supplemental Maternity Insurance - Infertility and IVF insurance coverage is not complete unless you also take steps to replace mom’s income when she misses work due to pregnancy complications, and during her maternity leave. Even if your employer offers a plan that pays for your Artificial Reproductive Technique (ART), you may have left over bills. Make sure your income is secure before getting pregnant. Once you become pregnant it will be too late.
Individuals Covered by IL Mandate
The IL infertility law provides detailed qualifications. The mandate applies to a woman who is not able to:
- Conceive after one year of unprotected sex, or
- Sustain a successful pregnancy
She may also qualify if she has been:
- Diagnosed with a medical condition that renders conception impossible, or
- Undergoing one year of medically supervised methods of conception, including artificial insemination
What is most interesting is that male infertility factors are not included in the list. Since the male accounts for 40% to 50% of infertility cases, this represents a significant hole in the mandate. Almost half of all couples may have to pay for infertility treatments themselves if the man is dealing with low sperm count, misshapen or immobile sperm, or blockages in seminal vesicles.
Any dependent under the age of 18 is excluded from the mandate.
What Infertility Procedures are Covered
The Illinois Infertility Health Insurance mandate is a law that requires health insurers to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility including:
- Prescription drugs
- Artificial insemination
- In Vitro fertilization (IVF)
- Gamete intrafallopian tube transfer (GIFT)
- Intracytoplasmic sperm injection (ICSI)
- Donor sperm and eggs (medical costs)
- Procedures utilized to retrieve oocytes or sperm
- Associated donor expenses
Unlimited IVF in Illinois
The Illinois law has two very interesting features relating to Artificial Reproductive Techniques (ART) requiring oocyte retrievals. First there is the variable limit of oocyte retrievals based upon whether you deliver a baby or not, and the second provides for an unlimited number of procedures to transfer the embryos back.
There is a limit of six retrievals per lifetime. This limit includes any retrieval another insurance carrier covered, or you paid for yourself. In order to reach the six oocyte benefit level you must demonstrate they work. The first limit is three. If you fail to deliver a baby your benefits cease. If you are able to deliver a baby, two more oocyte retrievals are now available to be covered.
The unlimited number of procedures to transfer back embryos makes for an interesting cost/benefit suggestion. “One completed oocyte-retrieval could result in many IVF, GIFT, ZIFT or ICSI procedures.” Fertility drugs are a covered benefit, and stimulate egg production. This benefit might encourage couples to maximize egg production. Egg storage costs are not included in the mandate, but fees are relatively small compared to the other covered benefits.
Do you get the picture? The very expensive components are covered with no limits. Make the most of each ooctyte-retrieval, and store those eggs. The payback is enormous!
Infertility Procedures Not Covered
The Illinois law has procedures that are excluded by commission and by omission. The procedures specifically excluded include:
- Reversal of voluntary sterilizations: vasectomy reversal, and tubal ligation reversal
- Services provided to a surrogate
- Storage of eggs, sperm, and embryos
- Experimental treatments
- Travel expenses
Procedures designed to overcome certain male infertility problems are excluded in the mandate by omission. The Illinois law covers only women. While transfer procedures such as IVF, GIFT, ZIFT, and ICSI are covered, certain procedures needed to increase sperm production might not be part of the mandated benefit. For example, Testicular Sperm Extraction (TSE) is not listed as a covered benefit, and since it involves only the male would not be a covered benefit.
Supplemental Insurance in Illinois for Infertility
You may find that your employer does offer health insurance with infertility coverage. And even if they do, you may find that you still have many left over bills. Be sure to take full advantage of our cost saving opportunities, and fund your maternity leave by purchasing supplemental health insurance before getting pregnant.
Remember that many fertility drugs stimulate egg production increasing the chances of conceiving multiples. If going the IVF route, your embryologist may implant multiple embryos to improve the odds of conception. This practice also leads to greater odds of conceiving twins or triplets. Multiple pregnancies are often high risk and may require bed rest prior to delivery – which may mean lost income you did not anticipate. When your infants are born they may come earlier than singleton births, requiring specialized care in the NICU, and perhaps leaving you with extra medical bills you did not budget for. Supplemental insurance addresses both needs.