PART 2015 INFERTILITY COVERAGE
CHAPTER I: DEPARTMENT OF INSURANCE
Section 2015.10 Purpose
(Source: Amended at 28 Ill. Reg. 12992, effective September 9, 2004)
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.
Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy. For purposes of this Part, a woman shall be considered infertile without having to engage in one year of unprotected sexual intercourse if a physician determines that:
a medical condition exists that renders conception impossible through unprotected sexual intercourse, including but not limited to congenital absence of the uterus or ovaries, absence of the uterus or ovaries due to surgical removal due to a medical condition, or involuntary sterilization due to chemotherapy or radiation treatments; or
efforts to conceive as a result of one year of medically based and supervised methods of conception, including artificial insemination, have failed and are not likely to lead to a successful pregnancy .
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.
(Source: Amended at 34 Ill. Reg. 2811, effective February 11, 2010)
- For treatments that include oocyte retrievals, coverage for such treatments shall be required only if the covered individual has been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments. This requirement shall be waived in the event that the covered individual or partner has a medical condition that renders such treatment useless.
- For treatments that include oocyte retrievals, coverage for such treatments is not required if the covered individual has already undergone four completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then coverage shall be required for a maximum of two additional completed oocyte retrievals. Such coverage applies to the covered individual per lifetime of that individual, for treatment of infertility, regardless of the source of payment.
- Following the final completed oocyte retrieval for which coverage is available, coverage for one subsequent procedure used to transfer the oocytes or sperm to the covered recipient shall be provided.
- The maximum number of completed oocyte retrievals that shall be eligible for coverage is six.
- When the maximum number of completed oocyte retrievals has been achieved, except as provided by subsection (b)(1) above, infertility benefits required under this Part shall be exhausted.
- The medical expenses of an oocyte or sperm donor for procedures utilized to retrieve oocytes or sperm, and the subsequent procedure used to transfer the oocytes or sperm to the covered recipient shall be covered. Associated donor medical expenses, including but not limited to physical examination, laboratory screening, psychological screening, and prescription drugs, shall also be covered if established as prerequisites to donation by the insurer.
- No group accident and health policy or health maintenance organization group contract which provides coverage as required by this Part shall exclude coverage for a known donor. In the event the insured or member does not have arrangements with a known donor, the health plan may require the use of a contracted facility. If the insured or member uses a known donor, the health plan may require the use of contracted providers by the donor for all medical treatment including, but not limited to, testing, prescription drug therapy and ART procedures, if benefits are contingent upon the use of such contracted providers.
- If an oocyte donor is used, then the completed oocyte retrieval performed on the donor shall count against the insured or member as one completed oocyte retrieval.
Section 2015.50 Minimum Benefit Standards
All diagnosis and treatment for infertility, including ART, shall be covered the same as any other illness or condition under the contract. A unique copayment or deductible shall not be applied to the coverage for infertility, including, but not limited to, ART or prescription drug therapy. If the policy or contract does not contain a prescription drug benefit, then one shall be established solely for coverage of prescription drug therapies for infertility.
Section 2015.60 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” as set forth in Section 2015.30 of this Part.
- 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.