IL is a mandate state. The text of the mandate I have C&P'ed below, but from what my clinic has said, it seems pretty common for companies to use loopholes in language to get out of covering as much as possible. I am very thankful that my company adheres to the text of the mandate completely but I'm a little uncomfortable talking about exactly what they cover.
llinois law requires insurance companies and HMOs to provide coverage
for infertility to employee groups of more than 25. The law does not
apply to self-insured employers or to trusts or insurance policies
written outside Illinois. However, for HMOs, the law does apply in
certain situations to contracts written outside of Illinois if the HMO
member is a resident of Illinois and the HMO has established a provider
network in Illinois.
Eligibility
To receive infertility coverage, you must:
- Live in Illinois,
- Be covered by a fully insured Illinois group policy through an employer with more than 25 full-time employees, and
- Have been unable to conceive after one year of unprotected sexual
intercourse between a male and female or have been unable to sustain a
successful pregnancy
Covered Expenses
Illinois requires group insurance and HMO plans to cover the
diagnosis and treatment of infertility the same as all other conditions.
For example, unique co-payments or deductibles cannot apply to
infertility coverage. Benefits shall include, but not be limited to:
- Testing
- Prescription drugs
- Artificial insemination
- Invitro fertilization (IVF)
- Gamete intrafallopian tube transfer (GIFT)
- Intracytoplasmic sperm injection (ICSI)
- Donor sperm and eggs (medical costs)
- Procedures utilized to retrieve oocytes or sperm and subsequent
procedures used to transfer the oocytes or sperm to the covered
recipient are covered
- Associated donor medical expense, including but not limited to
physical examination, laboratory screening, psychological screening, and
prescription drugs, are covered if established as prerequisites
Limitations
Benefits for advanced procedures such as IVF, GIFT, ZIFT or ICSI are
required only when a successful pregnancy through reasonable, less
costly medically appropriate infertility treatments for which coverage
is available under the policy is not successful.
The benefits for advanced procedures required by the law are four
completed oocyte retrievals per lifetime of the individual, except that
two completed oocyte retrievals are covered after a live birth is
achieved as a result of an artificial reproductive transfer of oocytes.
For example, if a live birth takes place as a result of the first
completed oocyte retrieval, then two more completed oocyte retrievals
for a maximum of three are covered under the law. If a live birth takes
place as a result of the fourth completed oocyte retrieval, then two
more completed oocyte retrievals for a maximum of six are covered. The
maximum number of completed oocyte retrievals that can be covered under
the law is six.
One completed oocyte retrieval could result in many IVF, GIFT, ZIFT
or ICSI procedures. There is no limit on the number of procedures,
including less invasive procedures such as artificial insemination. The
only limitations are on the number of completed oocyte retrievals.
Once the final covered oocyte retrieval is completed, one subsequent
procedure (IVF, GIFT, ZIFT, or ICSI) used to transfer the oocytes or
sperm is covered. After that, the benefit is maxed out and no further
benefits are available under the law.
Oocyte retrievals are per lifetime of the individual. If you had a
completed oocyte retrieval in the past that was paid for by another
carrier, or not covered by insurance, it still counts toward your
lifetime maximum under the law.
Exclusions
Your group insurance or HMO plan does not have to pay for:
- Costs incurred for reversing a tubal ligation or vasectomy
- Costs for services rendered to a surrogate, however, costs for
procedures to obtain eggs, sperm or embryos from a covered individual
shall be covered if the individual chooses to use a surrogate and if the
individual has not exhausted benefits for completed oocytes retrievals
- Costs of preserving and storing sperm, eggs and embryos
- Costs for an egg or sperm donor which are not medically necessary;
any fees for non-medical services paid to the donor are not covered
under the law
- Experimental treatments
- Costs for procedures which violate the religious and moral teachings or beliefs of the insurance company or covered group
Permissible Exclusions
- Reversal of voluntary sterilization; however, in the event a
voluntary sterilization is successfully reversed, infertility benefits
shall be available if the covered individual's diagnosis meets the
definition of "infertility".
- Payment for services rendered to a surrogate (however, costs for
procedures to obtain eggs, sperm or embryos from a covered individual
shall be covered if the individual chooses to use a surrogate);
- Costs associated with cryo preservation and storage of sperm, eggs,
and embryos; provided, however, subsequent procedures of a medical
nature necessary to make use of the cryo preserved substance shall not
be similarly excluded if deemed non-experimental and
non-investigational;
- Selected termination of an embryo; provided, however, that where the
life of the mother would be in danger were all embryos to be carried to
full term, said termination shall be covered;
- Non-medical costs of an egg or sperm donor;
- Travel costs for travel within 100 miles of the insured's or
member's home address as filed with the insurer or health maintenance
organization, travel costs not medically necessary, not mandated or
required by the insurer or health maintenance organization;
- Infertility treatments deemed experimental in nature. However, where
infertility treatment includes elements which are not experimental in
nature along with those which are, to the extent services may be
delineated and separately charged, those services which are not
experimental in nature shall be covered.
No insurer or HMO required to provide infertility coverage shall deny
reimbursement for an infertility service or procedure on the basis that
such service or procedure is deemed experimental or investigational
unless supported by the written determination of the American Society
for Reproductive Medicine (formerly known as the American Fertility
Society or the American College of Obstetrics). These entities will
provide such determinations for specific procedures or treatments only
and will not provide determinations on the appropriateness of a
procedure or treatment for a specific individual.
Coverage is required for all procedures specifically listed in Section
356m of the Illinois Insurance Code, entitled Infertility Coverage [215
ILCS 5/356m], regardless of experimental status; - Infertility treatments rendered to dependents under the age of 18.