Laws that mandate infertility coverage?

Question

I have researched out and found out that Illinois mandates insurance companies cover infertility treatments. I have printed out the documents on this. We have insurance through my hubby's employer (it has over 2,000 employees) but it states in our health insurance handbook that no infertility is covered at all. What is up with this and what can we do about it? Did they find a loop hole? Do I call our state and if so who or do we call our insurance company? Please help if you know anything about this. There are 13 states that mandate this. Thanks for the help.

Answer 1

Here's your loophole.

Illinois law requires insurance companies and HMOs to provide coverage for infertility to employee groups of more than 25. The law does NOT apply to self-insured employers or to trusts or insurance policies written OUTSIDE Illinois.

I'd venture that one of these exclusions is how your employer is not required to provide the coverage.

Answer 2

I found this info on the Illinois Insurance Commission web page:

http://www.idfpr.com/DOI/HealthInsurance...

Without knowing more info specifically about your insurance, I cannot answer more. There is a phone number listed for their office. I'm sure they can answer your questions specifically.

Answer 3

Insurance companies issue their policies out of one State so those are the laws  the policies will follow or, as is more often the case with large employers, the health plans are self- funded and self-insured health plans are not subject to state laws.  Self-funded plans are subject to the federal law the Employee Retirement Income Security Act (ERISA).

While it seems like a loop hole that gets an employer out of providing an employee certain benefits, there is also some logical to it.  It is impossible for an insurance company to compile with each State's insurance laws when issuing polices to multiple employers and employees in multiple states because the States insurance laws aren't consistent on what the benefits are on even a specific illness or treatment. For example, with infertility treatment, one State might mandate unlimited types of treatment with a maximum benefit of $10,000 while another State might include certain treatments and exclude others but have no dollar maximum.

Since your husband's employer has 2000 employees, they are probably self-funded and that means they have more decision-making power over what is and what is not covered under the health plan than an employer that is completely under the control of the health insurance company. What that means to you is that you can write a letter to the Human Resources Department or the Benefits Manager and ask if infertility treatment could be added to the company's health plan.  If you don't want to go at it as an exception in your case because the company has to apply health insurance benefits uniformly because they received tax incentives for the plan under Section 105 of the tax code. However, if you are comfortable with this process, gather as many signatures as you can on a petition, include the language of Illinois insurance mandate so you are clear on what you are asking for and possibily the company will add the benefit to the plan.  Good luck to you.

Answer 4

i never knew that.  Call your insurance company first and talk to them about it.  Like i said there are ways to get around all the tests, your doc that is covered by your insurance can prescribe certain tests and send all the info to your specailist.  You will definetly have to pay for there consultaion fee...that's all we had to pay for with both of the doctors working together.  Where do you live in illinois?  My specialist is in illinois he hads four locations!

Answer 5

Maybe the policy was not written in Illinois and that is a loophole they used to get out of it. Just a thought.

Answer 6

I have actually just had this issue personally.  While your insurance policy does not cover infertility, if you have a "wholly covered provider" and you are based out of Illinois, then the Illinois Mandate supercedes the policy.  Make sure to call the customer service number on your card and ask the question about the mandate.  Typically, if the insurance compay is not prompted, they just look at the policy itself, and don't take the next step to see if any mandates cover you.

I wish you the best of luck!!