In Illinois, we are lucky to be one of eight states with mandated fertility coverage. A recent update to the Illinois mandate has potentially widened the breadth of coverage now available to Illinois patients. Before addressing these updates, we’d like to explain background info first.
Understanding Insurance Mandates
A mandated state requires certain insurance plans to include a specific health insurance benefit. Mandates must be enacted by a state legislature, and start as a bill that is introduced, debated in committees, voted on by the state legislature and signed into the law by the governor. 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.
Exemptions from State Mandates
If an employer has its main headquarters located outside of Illinois, is self-insured or has less than 25 employees, they are exempt from the state mandate. Confirm with your HR or benefits department to confirm whether fertility services are covered on your insurance plan. 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.
State Definition of Infertility
To meet the definition of infertility set forth by the state mandate, a female patient must complete one year of unprotected intercourse in a woman under 35 years of age or six months in a women over 35 years of age.
Making the Most of Your Coverage
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.
Updates to the Illinois Mandate
Old Definition of Infertility in the IL IVF mandate: Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
New Definition of Infertility in the IL IVF mandate: 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 subtle, these updates change the definition of infertility and state that sexual intercourse is not a requirement for conception. This could open the mandate to single women and same sex couples, as well as broaden IVF access to those that have had cancer or another condition affecting fertility. We will have to see how insurance companies implement these changes moving forward.
The best way to ensure you are receiving proper coverage and all available benefits is to follow the three step checklist below.
Insurance Confirmation Checklist:
- Confirm with your benefits department whether your employer is self-insured or exempt from fertility coverage.
- Confirm with your insurance company whether your insurance plan provides diagnostic only coverage.
- Confirm with your insurance company how the mandate definition changes have affected your insurance coverage for infertility treatment and IVF.
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.
Financial Services Team
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.
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.
It is important to remember that we are here to support you and make your dream of family a reality. Our team is dedicated to your success and here with you every step of the way.
Dr. Meike Uhler, Reproductive Endocrinologist, Fertility Centers of Illinois
Barbara Collura, President/CEO, RESOLVE: The National Infertility Association