Section 2015.10  Purpose

 

The purpose of this Part is to establish uniform definitions of terms associated with infertility coverage and to establish minimum benefit standards for infertility coverage to be provided in this State.

 

Section 2015.20  Applicability and Scope

 

a)         This Part shall apply to all group accident and health insurance policies and health maintenance organization group contracts that are issued, amended, delivered or renewed in this State which provide pregnancy-related benefits for employees of an employer that has more than 25 full-time employees at the time of issue or renewal thereof. This Part does not apply to any coverage or policy that provides an excepted benefit, as that term is defined in Section 2791(c) of the federal Public Health Service Act (42 U.S.C. 300gg-91), to the extent provided in Section 352b of the Code.

 

b)         If a group policy is subject to both 42 U.S.C. 300gg-6(a), as implemented by the Illinois Essential Health Benefits (EHB) Benchmark Plan identified at 50 Ill. Adm. Code 2001.11(c)(2), and Section 356m of the Code, the policy shall provide infertility benefits that comply with both provisions, as well as any provision of this Part implementing an applicable statutory requirement for infertility benefits that is not superseded by current State or federal law.  For that policy, whenever Section 356m of the Code and the applicable Illinois EHB Benchmark Plan provide different minimum benefit standards such that one source requires coverage under an infertility benefit in a given situation and the other source does not or imposes a less stringent standard, whichever of the sources requires the most coverage will determine the minimum benefit standard for that situation under the policy.  Nothing in this subsection shall be construed to enlarge the scope of policies that are subject to 42 U.S.C. 300gg-6(a) or Section 356m of the Code.

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)

 

Section 2015.30  Definitions

 

For purposes of this Part and Section 356m of the Code:

 

"Artificial insemination" or "AI" means the introduction of sperm into an individual's vagina or uterus by noncoital methods, for the purpose of conception.

 

"Assisted reproductive technologies" or "ART" means treatments and/or procedures in which the human oocytes and/or sperm are retrieved and the human oocytes and/or embryos are manipulated in the laboratory.  ART shall include prescription drug therapy used during the cycle where an oocyte retrieval is performed.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Donor" means an oocyte donor or a sperm donor.

 

"Embryo" means a fertilized egg that has begun cell division and has completed the pre-embryonic stage.

 

"Embryo transfer" means the placement of the pre-embryo into the uterus or, in the case of zygote intrafallopian tube transfer, into the fallopian tube.

 

"Gamete" means a reproductive cell, which is either a sperm or an egg (ovum).

 

"Gamete intrafallopian tube transfer" or "GIFT" means the direct transfer of a sperm/egg mixture into the fallopian tube.  Fertilization takes place inside the tube.

 

"Gestational surrogacy" mean the process by which a woman attempts to carry and give birth to a child created through in vitro fertilization using the gamete or gametes of at least one of the intended parents.  [750 ILCS 47/10]  For purposes of this Part, the term applies whether or not the surrogate has made a genetic contribution to the child. 

 

"Infertility" has the meaning ascribed in Section 356m(c) of the Code.

 

"Infertility coverage" means insurance or health maintenance organization coverage required by Section 356m of the Code for the diagnosis and treatment, including prescription drug therapy, of infertility.

 

"In vitro fertilization" or "IVF" means a process in which an egg and sperm are combined in a laboratory dish where fertilization occurs.  The fertilized and dividing egg is transferred into the individual's uterus.

 

"Low tubal ovum transfer" means the procedure in which oocytes are transferred past a blocked or damaged section of the fallopian tube to an area closer to the uterus.

 

"Oocyte" means the egg or ovum, formed in an ovary.

 

"Oocyte donor" means an individual determined by a physician to be capable of donating eggs in accordance with the standards recommended by the American Society for Reproductive Medicine.

 

"Oocyte retrieval" means the procedure by which eggs are obtained by inserting a needle into the ovarian follicle and removing the fluid and the egg by suction. This is also called ova aspiration. Oocyte retrieval is included, for example, in the procedures for GIFT, IVF, and ZIFT.

 

"Pregnancy Related Benefit" means benefits that cover any related medical condition that may be associated with pregnancy, including complications of pregnancy.

 

"Surrogate" or "gestational surrogate" means a woman who agrees to engage in a gestational surrogacy.  [750 ILCS 47/10]

 

"Unprotected sexual intercourse" should include appropriate measures to ensure the health and safety of sexual partners and means, with respect to infertility benefits, sexual union involving the insertion of a penis into a partner's vagina without the use of any process, device or method that prevents conception, including but not limited to oral contraceptives, chemicals, physical or barrier contraceptives, natural abstinence or voluntary permanent surgical procedures. Without limiting any person’s actual or perceived gender identity, the term “woman” in Section 356m(c)(1) of the Code refers to the sexual partner with the vagina for purposes of this definition.

 

"Uterine embryo lavage" means a procedure by which the uterus is flushed to recover a preimplantation embryo.

 

"Zygote" means a fertilized egg before cell division begins.

 

"Zygote intrafallopian tube transfer" or "ZIFT" means a procedure by which an egg is fertilized in vitro and the zygote is transferred to the fallopian tube at the pronuclear stage before cell division takes place.  The eggs are harvested and fertilized on one day and the embryo is transferred at a later time.

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)

 

Section 2015.35  Benefit Limitation/Oocyte Retrieval Limitation

 

a)         For treatments that include oocyte retrievals, coverage shall be required if 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.  This requirement shall be waived in the event that the covered individual or partner has a medical condition that renders the less costly treatments useless.

 

b)         For treatments that include oocyte retrievals, coverage is not required if the covered individual has already undergone four completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then coverage shall be required for a maximum of two additional completed oocyte retrievals after the first live birth.  Such coverage applies to the covered individual per lifetime of that individual, for treatment of infertility, regardless of the source of payment.

 

1)         Following the final completed oocyte retrieval for which coverage is available, coverage for one subsequent procedure used to transfer the oocytes or sperm to the covered recipient or to a surrogate shall be provided.

 

2)         The policy or contract may provide a maximum number of completed oocyte retrievals for which the covered individual is eligible for coverage, which must be at least six (up to four cycles, plus an additional two after a live birth).

 

c)         When the maximum number of completed oocyte retrievals has been achieved, except as provided by subsection (b)(1), infertility benefits required under this Part shall be exhausted except with respect to the transfer of retrieved oocytes or resulting embryos to the covered recipient or a surrogate and other medically necessary fertility services until the covered individual or surrogate is discharged to regular obstetrical care.  However, nothing in this Part shall limit the coverage required by Section 356z.32 of the Code.

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)

 

Section 2015.40  Oocyte Retrieval Limitation (Repealed)

 

(Source:  Repealed at 28 Ill. Reg. 12992, effective September 9, 2004)

 

Section 2015.43  Donor Expenses

 

a)         The medical expenses of a donor for procedures utilized to retrieve oocytes or sperm, and the subsequent procedure used to transfer the oocytes or sperm to the covered recipient or to the surrogate shall be covered.  Associated donor medical expenses, including but not limited to physical examination, laboratory screening, psychological screening, and prescription drugs, shall also be covered if established as prerequisites to donation by the insurer.

 

b)         No group accident and health policy or health maintenance organization group contract that provides coverage as required by this Part shall exclude coverage for a known donor.  In the event the insured or member does not have arrangements with a known donor, the health plan may require the use of a contracted facility.  If the insured or member uses a known donor, the health plan may require the use of contracted providers by the donor for all medical treatment including, but not limited to, testing, prescription drug therapy and ART procedures, if benefits are contingent upon the use of such contracted providers.

 

c)         If an oocyte donor is used, then the completed oocyte retrieval performed on the donor shall count against the insured or member as one completed oocyte retrieval under Section 2015.35(b).

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)

 

Section 2015.50  Minimum Benefit Standards

 

a)         All diagnosis and treatment for infertility, including ART, shall be covered the same as any other illness or condition under the contract.  Except as provided in this Part and permitted under Section 356m of the Code, a unique copayment, coinsurance, deductible, benefit maximum, waiting period, exclusion, restriction, or other limitation shall not be applied to the coverage for the diagnosis or treatment of infertility, including, but not limited to, ART or prescription drug therapy, nor to the coverage for standard fertility preservation services required under Section 356z.32 of the Code.  If the policy or contract does not contain a prescription drug benefit, then one shall be established solely for coverage of prescription drug therapies for infertility.  Except as otherwise provided in this Part, infertility coverage shall include services to a surrogate and to a covered individual or the covered individual’s donor when a surrogate is arranged.  Fertility services rendered to a surrogate or donor to treat the covered individual's infertility shall be subject to and count toward the covered individual's cost-sharing requirements, benefit maximum, waiting period, network-based, and other exclusions, restrictions, or limitations.

 

b)         Nothing in this Part shall be construed to prohibit the use of the same medical management techniques and medical necessity criteria with a surrogate that the policy would apply to a covered individual for the same service, nor to prohibit the collection of the same information about the surrogate that would be collected about a covered individual for medical management of the service.

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)

 

Section 2015.60  Permissible Exclusions

 

a)         Reversal of voluntary sterilization; however, in the event a voluntary sterilization is successfully reversed, infertility benefits shall be available if the covered individual meets the definition of "infertility" as set forth in Section 2015.30 of this Part.

 

b)         Payment for services rendered to a surrogate after the surrogate has been discharged to regular obstetrical care, non-medical expenses incurred by the covered individual to contract with the surrogate, and any other services rendered to a surrogate that are not directly related to treatment of the covered individual’s infertility.  

 

c)         Expenses for cryopreservation and storage of sperm, eggs, and embryos. The exclusion must not apply to costs for subsequent procedures of a medical nature necessary to make use of the cryopreserved and stored substance if the procedures are deemed non-experimental and non-investigational. The exclusion also must not apply to expenses for cryopreservation when a covered individual receives those services under the conditions provided in Section 356z.32 of the Code relating to iatrogenic infertility; 

 

d)         Non-medical costs of a donor or a surrogate;

 

e)         Travel costs for travel within 100 miles of the insured's or member's home address as filed with the insurer or health maintenance organization, travel costs not medically necessary, not mandated or required by the insurer or health maintenance organization;

 

f)         Infertility treatments deemed experimental in nature.  However, where infertility treatment includes elements which are not experimental in nature along with those which are, to the extent services may be delineated and separately charged, those services which are not experimental in nature shall be covered.  No insurer or HMO required to provide infertility coverage shall deny reimbursement for an infertility service or procedure on the basis that such service or procedure is deemed experimental or investigational unless supported by the written determination of the American Society for Reproductive Medicine (formerly known as the American Fertility Society or the American College of Obstetrics).  These entities will provide such determinations for specific procedures or treatments only and will not provide determinations on the appropriateness of a procedure or treatment for a specific individual.  Coverage is required for all procedures specifically listed in Section 356m of the Code, regardless of experimental status.

 

(Source:  Amended at 47 Ill. Reg. 143, effective December 20, 2022)