What Does the Illinois Fertility Insurance Mandate Cover?

Illinois has one of the more detailed infertility coverage laws in the country. In plain terms, some health plans that cover pregnancy-related care must also cover infertility diagnosis and treatment, including IVF and related procedures ASRM.

Key takeaways

• Illinois requires certain group health plans with pregnancy-related benefits to cover infertility treatment.
• Covered treatment can include diagnosis of infertility, IVF, embryo transfer, artificial insemination, GIFT, ZIFT, and low tubal ovum transfer.
• IVF, GIFT, and ZIFT are covered only after less costly infertility treatments covered by the plan have not worked.
• The law limits coverage to four egg retrievals, with two more allowed if a live birth occurs, for a lifetime maximum of six.
• Small employers, religious employers, and self-insured employers are exempt from the mandate ASRM.
• Illinois also separately requires certain plans to cover medically necessary fertility preservation when a medical treatment may directly or indirectly cause iatrogenic infertility ASRM.

What does the Illinois fertility insurance mandate require?

The Illinois mandate requires group insurers and HMOs that provide pregnancy-related coverage to cover infertility treatment. Covered services include diagnosis of infertility, IVF, uterine embryo lavage, embryo transfer, artificial insemination, GIFT, ZIFT, and low tubal ovum transfer ASRM.

That means the law is not just about one procedure. It reaches a range of infertility services, from testing and diagnosis to several assisted reproductive technologies. But the mandate is tied to the kind of health plan being offered: it applies to plans that already include pregnancy-related benefits and are subject to the Illinois rule ASRM.

Which treatments are included?

Illinois lists several specific treatments that must be covered when the mandate applies. Those include IVF, GIFT, ZIFT, embryo transfer, artificial insemination, uterine embryo lavage, low tubal ovum transfer, and diagnosis of infertility ASRM.

For many people, the most important detail is that IVF is included, but not on an unlimited basis. The law treats IVF, GIFT, and ZIFT as higher-level treatments that come into play only after less costly, medically appropriate infertility treatments covered by the plan have not led to a successful pregnancy ASRM.

That sequencing matters because it creates a stepwise approach. Lower-cost options must be tried first if they are covered and medically appropriate. Only then does the mandate require coverage for these more advanced procedures ASRM.

How many egg retrievals does Illinois cover?

Illinois caps covered egg retrievals at four per patient. If a live birth occurs, the plan must cover two additional retrievals, bringing the lifetime maximum to six covered retrievals ASRM.

This is an important limit because egg retrieval is a core step in IVF and some related treatments. The cap is not described as an annual limit; instead, it is a lifetime maximum tied to the number of completed retrievals ASRM.

The law also states that IVF, GIFT, and ZIFT must be covered only if the covered individual has not already undergone four completed oocyte retrievals, with the same exception for two more retrievals after a live birth ASRM.

Who has to comply with the mandate?

The mandate applies to group health policies that offer pregnancy-related benefits and cover more than 25 employees. In other words, it is aimed at certain group plans rather than every health policy in the state ASRM.

Illinois also requires individual or group health or accident insurance policies amended, delivered, issued, or renewed in Illinois after January 1, 2019, to cover medically necessary fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility ASRM.

That fertility preservation requirement is separate from the infertility treatment mandate. It applies when a medical treatment could harm fertility, such as through surgery, radiation, chemotherapy, or another treatment affecting reproductive organs or processes ASRM.

What is iatrogenic infertility in Illinois?

Iatrogenic infertility means fertility impairment caused by medical care. Illinois defines it as an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes ASRM.

The fertility preservation rule uses this definition to require coverage for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause that kind of infertility. “Standard fertility preservation services” are based on current evidence-based standards of care developed by national medical associations ASRM.

What plans and employers are exempt?

Illinois does not require every employer to offer this coverage. Employers with fewer than 25 employees are exempt, and the law does not require religious employers to cover infertility treatment ASRM.

Self-insured employers are also exempt from the mandate ASRM. That distinction matters because self-insured plans are governed differently from fully insured plans, and state insurance mandates generally apply to the latter rather than the former Healthcare.gov.

There is one additional caveat for fertility preservation coverage. If HHS requires the state, under the Affordable Care Act, to defray the cost of fertility preservation coverage, then that fertility preservation coverage is no longer operative ASRM.

How does the plan have to make coverage decisions?

For IVF, GIFT, and ZIFT, Illinois requires that the person first be unable to attain or maintain a viable pregnancy, or have a successful pregnancy, through less costly medically appropriate infertility treatment that the plan covers. The procedures also must be performed at medical centers that conform to standards set by the American College of Obstetric and Gynecology or the American Fertility Society ASRM.

That means the mandate is not unlimited coverage for every clinic or every situation. It builds in both medical sequencing and facility standards. The law ties coverage to treatment setting as well as to treatment type ASRM.

What this means in everyday terms

If you are comparing plans in Illinois, the key questions are whether the plan is fully insured, whether it includes pregnancy-related benefits, and whether your employer is small enough or structured in a way that makes it exempt. If the mandate applies, the plan must cover infertility diagnosis and several common fertility treatments, but IVF-type care is still subject to a step therapy approach and a lifetime retrieval cap ASRM.

The practical takeaway is that Illinois coverage can help with fertility care, but it is not open-ended. The law combines required benefits with limits on how many retrievals are covered and with several employer and plan exemptions ASRM.

Why the distinction between infertility treatment and fertility preservation matters

People often think of fertility coverage as one bucket, but Illinois separates two different situations. Infertility treatment coverage addresses difficulty achieving or maintaining pregnancy. Fertility preservation coverage addresses the risk of future infertility caused by medical treatment, such as cancer therapy or other procedures that may affect reproductive organs ASRM.

That separation can matter a lot when you are reading a health plan. A plan might fall under the infertility mandate, the fertility preservation rule, both, or neither, depending on the policy type and employer structure ASRM.

Bottom line

Illinois requires many fully insured group plans with pregnancy-related coverage to include infertility diagnosis and treatment, including IVF and related procedures. The mandate comes with clear limits: four covered egg retrievals, two more after a live birth, and coverage only after less costly treatments have not worked. Small employers, religious employers, and self-insured employers are exempt, and a separate rule requires certain plans to cover fertility preservation when medically necessary treatment may cause iatrogenic infertility ASRM.