§ 356m — Infertility coverage

Illinois § 356m

• Jurisdiction: Illinois
• Topic: REGULATION
• Ch. 215: INSURANCE
• Act 215 ILCS 5/: Illinois Insurance Code.
• Art.: Article XX - Accident And Health Insurance

Text

(a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State after January 1, 2016 and through December 31, 2025 unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer. (a-5) No group policy of accident and health insurance that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State on or after January 1, 2026 unless the policy contains coverage for the diagnosis and treatment of infertility, including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, surgical sperm extraction procedures, and low tubal ovum transfer. The coverage required shall include procedures necessary to screen or diagnose a fertilized egg before implantation, including, but not limited to, preimplantation genetic testing for aneuploidy, preimplantation genetic testing for chromosome structural rearrangements, and preimplantation genetic testing for monogenic or single gene disorders. Coverage under this subsection for the diagnosis and treatment of infertility shall be required only if the procedures: (1) are considered medically appropriate by the patient's medical provider based on clinical guidelines or standards developed by the American Society for Reproductive Medicine, the American College of Obstetricians and Gynecologists, or the Society for Assisted Reproductive Technology; and (2) are performed at medical facilities or clinics that are members in good standing of the Society for Assisted Reproductive Technology. (b) The coverage required under subsection (a) for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if: (1) the covered individual has been unable to attain a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract; (2) the covered individual has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and (3) the procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization. (c) As used in this Section, "infertility" means a disease, condition, or status characterized by: (1) a failure to establish a pregnancy or to carry a pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility; (2) a person's inability to reproduce either as a single individual or with a partner without medical intervention; or (3) a licensed physician's findings based on a patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing. (d) A policy, contract, or certificate may not impose any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications, nor may it impose any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party, nor may it impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, except as provided in this Section, that are different from those imposed upon benefits for services not related to infertility. (e) The procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.

Legislative History

(Source: P.A. 102-170, eff. 1-1-22; 103-751, eff. 8-2-24.)