Illinois Infertility Insurance Mandate
Text of the Illinois Infertility Law (215 ILCS 5/356m)
Sec. 356m. Infertility coverage.



(a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy related benefits may be issued, amended, delivered, or renewed in this State after the effective date of this amendatory Act of 1991 unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.

(b) The coverage required under subsection (a) is subject to the following conditions:

(1) Coverage for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:

(A) The covered individual has been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;

(B) the covered individual has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and

(C) the procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.

(2) the procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.

(c) For purpose of this Section, "infertility" means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
(Source: P.A. 89-669, effective 1-1-97.)


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Text of the Illinois Infertility Regulation (Part 2015)
Section
2015.10 Purpose
2015.20 Applicability and Scope
2015.30 Definitions
2015.40 Oocyte Retrieval Limitation
2015.50 Minimum Benefit Standards
2015.60 Permissible Exclusions

AUTHORITY: Implementing Section 356m of the Illinois Insurance Code, entitled Infertility Coverage (Ill. Rev. Stat. 1991, ch. 73, par. 968m) [215 ILCS 5/356m] and Section 5-3 of the Health Maintenance Organization Act (Ill. Rev. Stat. 1991, ch. 111 1/2, par. 1411.2)[215 ILCS 125/5-3] and authorized by Section 401 of the Illinois Insurance Code (Ill. Rev. Stat. 1991, ch. 73, par. 1013) [215 ILCS 5/401].

SOURCE: Adopted at 17 Ill. Reg. 8170, effective May 20, 1993.

2015.10 Purpose

The purpose of this Part is to establish uniform definitions of terms associated with infertility coverage and to establish minimum benefit standards for infertility coverage to be provided in this State.

2015.20 Applicability and Scope

This Part shall apply to all group accident and health insurance policies and health maintenance organization group contracts which provide pregnancy related benefits for employees of an employer which has more than 25 employees at the time of issue or renewal thereof, and which are issued, amended, delivered or renewed in this State on or after the effective date of this Part.

2015.30 Definitions

Artificial Insemination (AI) means the introduction of sperm into a woman's vagina or uterus by noncoital methods, for the purpose of conception.

Assisted Reproductive Technologies (ART) means treatments and/or procedures in which the human oocytes are retrieved and the human oocytes and/or embryos are manipulated in the laboratory. ART shall include prescription drug therapy used during the cycle where an oocyte retrieval is performed.

Embryo means a fertilized egg that has begun cell division and has completed the pre-embryonic stage.

Embryo Transfer means the placement of the pre-embryo into the uterus or, in the case of zygote intrafallopian tube transfer, into the fallopian tube.

Gamete means a reproductive cell. In a man, the gametes are sperm; in a woman, they are eggs or ova.

Gamete Intrafallopian Tube Transfer (GIFT) means the direct transfer of a sperm/egg mixture into the fallopian tube. Fertilization takes place inside the tube.

Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy. Section 356m(c) of the Illinois Insurance Code (Ill. Rev. Stat. 1991, ch. 73, par. 968m) [215 ILCS 5/356m(c)].

Infertility Coverage means insurance or health maintenance organization coverage required by Section 356m of the Illinois Insurance Code (Ill. Rev. Stat. 1991, ch. 73, par. 968m) [215 ILCS 5/356m] for the diagnosis and treatment, including prescription drug therapy, of infertility.

In Vitro Fertilization (IVF) means a process in which an egg and sperm are combined in a laboratory dish where fertilization occurs. The fertilized and dividing egg is transferred into the woman's uterus.

Low Tubal Ovum Transfer means the procedure in which oocytes are transferred past a blocked or damaged section of the fallopian tube to an area closer to the uterus.

Oocyte means the female egg or ovum, formed in an ovary.

Oocyte Retrieval means the procedure by which eggs are obtained by inserting a needle into the ovarian follicle and removing the fluid and the egg by suction. Also called ova aspiration.

Pregnancy Related Benefit means benefits that cover any related medical condition that may be associated with pregnancy, including complications of pregnancy.

Sexual Intercourse means sexual union between a male and a female.

Uterine Embryo Lavage means a procedure by which the uterus is flushed to recover a preimplantation embryo.

Zygote means a fertilized egg before cell division begins.

Zygote Intrafallopian Tube Transfer (ZIFT) means a procedure by which an egg is fertilized in vitro and the zygote is transferred to the fallopian tube at the pronuclear stage before cell division takes place. The eggs are harvested and fertilized on one day and the embryo is transferred at a later time.

2015.40 Oocyte Retrieval Limitation

For treatments that include oocyte retrievals, coverage for such treatments is not required if the covered individual has already received four completed oocyte retrievals, per lifetime of said individual; except that if a live birth follows a completed oocyte retrieval, then coverage is required for two additional completed oocyte retrievals.

2015.50 Minimum Benefit Standards

A unique co-payment or deductible shall not be applied to coverage for ART or for prescription drug therapy used in conjunction with ART;
All diagnosis and treatment for the disease infertility shall be covered the same as any other illness or condition under the contract.

2015.60 Permissible Exclusions

• Reversal of voluntary sterilization;
• Payment for medical services rendered to a surrogate for purposes of childbirth;
• 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 one hundred (100) miles of the members' 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 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 (Ill. Rev. Stat. 1991, ch. 73, par. 968m) [215 ILCS 5/356m], regardless of experimental status.