Does Insurance Cover IVF in Illinois?

Infertility presents personal and financial challenges. Understanding how health insurance benefits apply to fertility treatments, such as in vitro fertilization (IVF), is crucial. For Illinois residents, insurance coverage for fertility care is shaped by state mandates designed to expand access. These mandates clarify potential coverage and the responsibilities of insurers and policyholders.

Illinois Insurance Mandate for Infertility Coverage

Illinois has a state mandate requiring certain health insurance plans to cover the diagnosis and treatment of infertility. This mandate is codified under the Illinois Insurance Code, 215 ILCS 5/356m. This law dictates that group health insurance policies and health maintenance organizations (HMOs) offering pregnancy-related benefits must include infertility treatment coverage. The mandate applies to policies issued or renewed within Illinois.

For the mandate to apply, an insurance plan must cover groups of more than 25 employees. The law stipulates that infertility coverage cannot be subjected to unique co-payments or deductibles that differ from those applied to other medical conditions.

Starting January 1, 2026, a new law will broaden this requirement, mandating that every group health insurance policy cover the diagnosis and treatment of infertility. This update reflects an ongoing commitment to making fertility treatments more accessible.

Specific Services and Conditions for Coverage

The Illinois mandate details specific services that must be covered for infertility diagnosis and treatment. These include diagnostic testing, prescription medications, and various assisted reproductive technologies. Covered procedures encompass:

Artificial insemination (IUI)
In vitro fertilization (IVF)
Uterine embryo lavage
Embryo transfer
Gamete intrafallopian tube transfer (GIFT)
Zygote intrafallopian tube transfer (ZIFT)
Low tubal ovum transfer
Intracytoplasmic sperm injection (ICSI)
Medical costs associated with donor sperm or eggs

Coverage for these treatments is subject to a medical diagnosis of infertility. The law defines infertility as the inability to conceive after one year of unprotected sexual intercourse if the woman is under 35, or after six months if she is 35 or older. This definition also extends to individuals diagnosed with a medical condition preventing conception or those who cannot reproduce without medical intervention, including single individuals or partners. Treatments must be medically necessary.

For complex procedures like IVF, GIFT, and ZIFT, coverage requires less costly, medically appropriate infertility treatments to have been attempted and proven unsuccessful. The mandate specifies limits on oocyte retrievals, covering up to four retrievals per lifetime. If a live birth occurs, two additional retrievals are covered, for a maximum of six retrievals total. While retrievals have limits, there is no specified limit on subsequent IVF, GIFT, ZIFT, or ICSI procedures resulting from a single retrieval. All covered procedures must be performed at medical facilities adhering to guidelines set by organizations like the American College of Obstetricians and Gynecologists (ACOG) or the American Society for Reproductive Medicine (ASRM).

Exemptions and Limitations to Coverage

While Illinois’s mandate is comprehensive, certain exemptions and limitations exist. A significant exemption applies to self-funded health plans, often referred to as ERISA plans. These plans are regulated by federal law, not state law, and are therefore exempt from state-level mandates. Individuals can determine if their plan is self-funded by contacting their employer’s human resources department or the plan administrator.

An exemption may apply to religious employers. If a religious institution or organization believes the mandated procedures violate its religious and moral teachings, its insurance plan may not be required to cover those specific treatments. The mandate also does not apply to small employers with fewer than 25 employees.

Policies written outside of Illinois, individual health plans, and Medicaid are not subject to this state mandate. While the mandate aims to provide broad access, these specific plan types fall outside its scope, though some exceptions may apply for HMOs with established networks in Illinois. Certain items are not covered, such as procedures to reverse voluntary tubal ligations or vasectomies, or costs for services rendered to a surrogate (though costs to obtain eggs, sperm, or embryos from the covered individual for surrogacy are covered). Experimental treatments are also excluded from coverage.

Navigating Your Coverage and Costs

Understanding your individual insurance policy is crucial for utilizing fertility benefits. Even with the Illinois mandate, contact your insurance provider directly. Request a detailed breakdown of your infertility benefits, including any exclusions or limitations. This review clarifies covered procedures and conditions.

When speaking with your insurer, inquire about financial details such as deductibles, co-payments, co-insurance, and out-of-pocket maximums. These are the amounts you will pay before insurance covers the full cost. Understand any pre-authorization requirements for fertility treatments, as many procedures need prior approval. Confirming whether your chosen fertility clinic and specialists are in-network or out-of-network is also important, as this significantly impacts your financial responsibility.

If a claim for fertility treatment is denied, you have options for recourse. Initiate an internal appeal with your insurance company, providing additional medical documentation. If the internal appeal is unsuccessful, you may have the right to an external review by an independent third party. The Illinois Department of Insurance enforces the state’s mandates; you can file a complaint if you believe your plan is not complying with the law.