At the same time the mandated benefits do not apply to every individual. There are precise definitions to follow, along with exclusions, limitations, and loopholes. Below is an outline of topics covered in more detail below:
- What benefits are required?
- How does it work with IVF?
- What are the limitations?
IL Infertility Mandated Benefit Requirements
The Illinois infertility insurance mandated benefits list is very long compared to comparable laws in other states. The language supporting the law is very precise about what benefits are required, and which are not. Benefits for male factor infertility are excluded by omission.
The Illinois infertility insurance mandated benefits require health insurers to provide coverage for medically necessary expenses incurred in diagnosis and treatment of infertility including:
- Prescription drugs
- Artificial insemination
- Gamete intrafallopian tube transfer (GIFT)
- In vitro fertilization (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Donor sperm and eggs (medical costs)
- Procedures utilized to retrieve oocytes or sperm
- Associated donor expenses
The Illinois law has procedures that are excluded by commission and by omission. The procedures specifically excluded include:
- Reversal of voluntary sterilizations:
- Vasectomy reversal
- 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.
Illinois IVF Law
The Illinois infertility insurance law gets very interesting when applied to In Vitro Fertilization. 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.
Success-based Retrieval Limits
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.
Supplemental health insurance for IVF proves most valuable when success rates are high.
Unlimited Embryo Transfers
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!
IL Infertility Insurance Mandate Limitations
The Illinois infertility insurance mandate places limitations on who is required to comply. While the mandated benefits are extensive and very rich, the number of people covered is less extensive. There is a variety of qualifying criteria that apply to employer sponsored group health plans, and also to the individuals.
Employer Group Limitations
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. No interest infertility financing may help those working for non covered employers.
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 with that state’s rules. 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.
Limitations Applied to Individuals
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.
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