Coverage Mandate 1:
Effective January 1, 2016
All group health or accident insurance policies which cover more than 25 employees and already offer pregnancy related benefits must cover the diagnosis and treatment of infertility. This includes, non-exhaustively, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.
215 Ill. Comp. Stat. 5/356m (2016).
“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.215 Ill. Comp. Stat. 5/356m(c) (2016).
Scope of Mandate 2:
Coverage Cap 3:
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
Yes, for religious organizations.
Religious institutions or organizations, or entities sponsored by a religious institution or organization religiously or morally opposed to the procedures in this section do not have to cover infertility procedures.215 Ill. Comp. Stat. 5/356m(b)(2) (2016).
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).
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.