Financing fertility treatment can be a significant challenge for many families. Since most health insurance coverage is provided through an employer, the first step to financing treatment often begins at work.
Illinois Coverage Mandate
Illinois is one of the states that mandates fertility coverage for certain employers. Under the Illinois Insurance Code, companies that provide group health insurance, have 25 or more employees, and provide pregnancy related coverage must provide fertility treatment including, but not limited to: diagnosis of infertility; in vitro fertilization (IVF); embryo transfer; artificial insemination; gamete intrafallopian transfer (GIFT); and zygote intrafallopian transfer (ZIFT). Coverage for IVF, GIFT and ZIFT is provided if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, fertility treatments covered by insurance.
Under the coverage mandate, each patient is covered for up to 4 egg retrievals. However, if a live birth occurs, two additional egg retrievals will be covered, with a lifetime maximum of six retrievals covered. The procedures must be performed at facilities that conform with American College of Obstetricians and Gynecologists (ACOG) and American Society for Reproductive Medicine (ASRM) guidelines, such as AFCC.
The coverage mandate also applies to fertility preservation, specifically to any individual or group health or accident insurance policy amended, delivered, issued, or renewed in Illinois after Jan 1, 2019.
These plans must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical service may directly or indirectly cause iatrogenic infertility (impair the fertility). Please note that in many cases, “medical necessity” would only apply to life-threatening diagnoses, such as a cancer diagnosis, in order for insurance to cover the fertility preservation services.
Coverage Exemptions
- Employers with fewer than 25 employees do not have to provide coverage.
- The mandate does not require religious employers to cover fertility treatment.
- Employers who self-insure are exempt from the requirements of the law.
Talking to Your Employer About Fertility Care Coverage
To determine if your employer-provided health plan covers fertility treatment, start by speaking with the benefits contact in your human resources department. You can also call the customer service number on the back of your insurance card for information about your coverage.
When inquiring, you’ll want to ask more than just whether or not fertility treatment is covered. If your employer offers multiple health plans, consider asking the following questions:
- Which plans, if any, provide fertility treatment coverage? This is especially useful to know during open enrollment if you’re considering switching plans.
- Are there waiting periods before you can access fertility benefits?
- What specific procedures are covered, and are there any age limits on coverage?
Just because a plan offers coverage doesn’t mean it covers all aspects of treatment. If your plan does include fertility coverage, consider these additional steps:
- Request a written copy of the plan to review the details thoroughly.
- Confirm your deductible, co-pay, and network details to avoid surprises.
- Determine if pre-authorizations are required for treatments, and understand the process for obtaining them.
- Review your plan periodically during treatment to stay informed about what’s covered and what costs you may incur.
Our financial counselors at AFCC are available to help guide you through your insurance plan and answer any questions you may have. We encourage you to take advantage of this resource to fully understand your options.
What if Your Employer Doesn’t Offer Fertility Insurance Coverage?
If your employer doesn’t provide fertility insurance coverage, consider asking them to add it. The case for including fertility coverage is compelling—the World Health Organization (WHO) estimates that 1 in 6 individuals are impacted by infertility, globally. Given its prevalence, it makes sense for employers to support employees facing infertility.
Incorporating fertility treatment into group health plans generally does not significantly raise insurance premiums. In fact, offering fertility coverage can reduce costs overall by allowing patients to choose treatments based on medical needs rather than financial constraints. For example, if a plan covers multiple IVF cycles, patients may opt for fewer embryo transfers per cycle, reducing the risk of costly multiple births.
RESOLVE, a national infertility association, offers a variety of resources to help you advocate for fertility coverage with your employer. Their resources include sample letters and talking points for both employees and employers.
Additionally, if you’re a patient living in Illinois, you may be able to purchase an additional, self-funded insurance policy through HealthCare.gov, which will offer fertility treatment coverage following the Illinois state mandate. Any policies purchased through HealthCare.gov would require patients to pay a monthly premium, deductible, and/or coinsurance amounts.
Being an informed advocate is key to navigating your fertility journey. If you need assistance, we’re here to help.
Fertility Insurance Coverage FAQs
How do I know if I have fertility treatment coverage? Review your health insurance policy or contact your insurance provider to check for specific language regarding fertility treatment and coverage details.
Can I pay for fertility treatment out of pocket? Yes, fertility treatments can be paid for out of pocket. The costs vary depending on the type of treatment and other factors.
Are there alternatives for financing fertility treatment in Illinois? At Advanced Fertility Center of Chicago, we offer several financing options to help make fertility treatment more affordable, through PatientFi, Future Family, and Lending Club.
Learn More About Fertility Insurance Coverage in Illinois
If you’re considering fertility care and want to know more about your insurance options, we encourage you to connect with Advanced Fertility Center of Chicago. Our team is here to guide you through your fertility journey, ensuring you make the most of your insurance benefits. Contact us today to learn more!
