Illinois Family Building Act
The Illinois Family Building Act of 1991 (rev 1997) entitles, under law, insurance benefit coverage for fertility care for most Illinois residents. This includes the diagnosis and treatment of infertility. The law defines infertility as the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
Who is Covered?
Any women who receives coverage under a fully-insured group policy of accident and health insurance or HMO contract for a group larger than 25 who:
- Is unable to conceive after one year of unprotected sexual intercourse;
- Is unable to sustain a successful pregnancy;
- Has been diagnosed by a physician as having a medical condition that renders conception impossible through unprotected sexual intercourse; or
- Has undergone one year of medically based and supervised methods of conception, including artificial insemination, which a physician has determined to have failed and are not likely to lead to a successful pregnancy.
What Services are Covered?
The Illinois Family Building Act insurers the coverage for infertility treatment which includes but is not limited to:
- Fertility Diagnostic Testing
- Intra-Uterine Insemination (IUI), also known as artificial insemination
- In Vitro Fertilization (IVF)*
- Uterine Embryo Lavage
- Embryo Transfer
- Zygote Intrafallopian Tube Transfer (ZIFT)*
- Gamete Intrafallopian Tube Transfer (GIFT)*
- Low Tubal Ovum Transfer
- Intracytoplasmic Sperm Injection (ICSI)
- Medical Costs associated with Donor Sperm and Donor Eggs
- Medical Procedures associated with use to retrieve oocytes or sperm
- Medical Procedures utilized to transfer oocytes or sperm to covered recipient
- Prescription Drugs
- Medical expenses related to Donor, including but not limited to examinations, psychological evaluation and prescription drugs as a requirement to donation by the insurer
*Coverage for IVF, ZIFT, GIFT is provided if and ONLY IVF, the patient has been unable to conceive or sustain a successful pregnancy through the reasonable use of less costly fertility treatment options for which coverage is available.
NOTE: Coverage for advanced treatment procedures is limited to four completed Oocyte retrievals per lifetime of the individual, except that two completed oocyte retrievals are covered after a successful live birth is achieved as a result of an artificial reproductive transfer of oocytes. For example, if a live birth takes place as a result of the first completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of three are covered under the law. If a live birth takes place as a result of the fourth completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of six are covered. The maximum number of completed oocyte retrievals that can be covered under the law is six.
One completed oocyte retrieval could result in many IVF, GIFT, ZIFT or ICSI procedures. There is no limit on the number of procedures, including less invasive procedures such as artificial insemination. The only limitations are on the number of completed oocyte retrievals.
NOTE: Once the final covered oocyte retrieval is completed, one subsequent procedure (IVF, GIFT, ZIFT, or ICSI) used to transfer the oocytes or sperm is covered. After that, the benefit is maxed out and no further benefits are available under the law.
NOTE: Oocyte retrievals are per lifetime of the individual. If you had a completed oocyte retrieval in the past that was paid for by another carrier, or not covered by insurance, it still counts toward your lifetime maximum under the law.
What is Not Covered?
Your group insurance or HMO plan does not have to pay for:
- Costs incurred for reversing a tubal ligation or vasectomy
- Costs for services rendered to a Surrogate, however, costs for procedures to obtain eggs, sperm or embryos from a covered individual shall be covered if the individual chooses to use a surrogate and if the individual has not exhausted benefits for completed oocytes retrievals
- Costs of preserving and storing sperm, eggs and embryos
- Costs for an egg or sperm donor which are not medically necessary
- Experimental treatments
- Costs for procedures which violate the religious and moral teachings or beliefs of the insurance company or covered group
- The patient’s employer doesn’t have to provide fertility benefit coverage if:
- Patient works for an employer that employs fewer than 25 employees
- The Employer is Self-Insured
- Patient’s employer is headquartered outside of Illinois
- Patient’s group insurance policy was bought through a trust
- Patient’s employer is a religious institution or organization in which procedures may violate their religion or beliefs
- Patient or patient’s spouse voluntarily sterilized him/her without first attempting to reverse the sterilization
- Previously completed lifetime maximum of egg retrievals
IMPORTANT: MCRM’s insurance verification team will make all appropriate attempts to verify your insurance coverage prior to your initial appointment. Please note this is provided as a courtesy only and is not a guarantee of benefits . Please understand that the patient is ultimately responsible for all non-coverage or under paid services provided by MCRM. MCRM is not responsible for any incorrect information that the insurance company may provide or any omitted information regarding limited/non-benefits or waiting periods. Be aware that any deductible amounts that are not met must be paid at the time of service and co-pays must be paid at the time of each visit.
To discuss further whether or not you are covered under this ACT, please contact us today.