We know that talking to insurance companies can be confusing. To make this easier for you, we’d like to take you through the different factors that go into insurance coverage and discuss questions to ask both your employer and insurance company.
In Illinois, we are lucky to be one of 15 states with mandated fertility coverage. A mandated state requires certain insurance plans to include a specific health insurance benefit. The mandate that requires certain insurance plans to cover IVF in Illinois was passed in 1991, and has been updated a few times since then.
Illinois IVF mandate language: 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.
While we are in a mandated state, there are different factors that can make an employer exempt from a fertility coverage mandate. Companies that fall within any of the parameters below are exempt:
- Employers with their main headquarters outside of Illinois
- Employers that are self-insured
- Employers with less than 25 employees
Questions to ask your employer:
- Are fertility services covered on the insurance plan?
- Where is the main headquarters located?
- Are you self-insured?
- How many employees do you have?
Health insurance with the federal government also does not adhere to state mandates. This includes federal employees, TRICARE for the military, Veterans Administration benefits, Medicaid and Medicare.
For those who do not have coverage through their employer, it may be possible to purchase additional insurance to cover fertility treatment benefits.
Those with insurance coverage through their employer should then prepare to discuss the details of their coverage with their insurer.
Before making an appointment or completing any tests, it is important to confirm whether you have “diagnostic only” coverage. This coverage designation only covers testing and does not cover treatment. This coverage plan applies to as many of 20% of patients. For those with this plan, it is important to complete all testing before moving forward with treatment such as ovulation induction. Once treatment has started no further testing is covered. With this plan, patients are considered self-pay for all infertility treatment services.
Questions to ask your insurer:
- What fertility treatment services are covered?
- Is coverage diagnostic only?
- Do any or what requirements exist to receive coverage? (ie must complete certain tests, etc)
- Is there a limit on cycles that are covered?
- Do limits apply for life, or do they update every year?
Always get a reference number from the insurance agent you are speaking with to document the call. If your claim is rejected, seek a review of the claim (called an appeal) and fight for your rights. Many claims that are initially rejected can be overturned, simply by the covered person requesting an appeal of a rejected claim.
At Fertility Centers of Illinois we have a team dedicated to assessing fertility coverage and advocating on behalf of the patient with insurance companies. Should coverage not be possible, there are financing options such as fertility financing with CapexMD as well as several payment programs and discounts for self-pay patients. To learn more about financing options and available discounts, click here.
Patients can also access discounted or free treatment by participating in a research study, should they meet study eligibility requirements. Grant programs from the LIFE Foundation and CADE Foundation can also reduce the cost of treatment.