Parents should add their adopted children to their health insurance immediately upon placement of the child into their home. Some insurance providers may try to deny coverage of the adopted child insisting that parents provide them with a "final adoption order" before they will add the child. IN MOST CASES this is not true.

Most group health plans are subject to Section 609(c) of the Employee Retirement Income Security Act of 1974 (ERISA) which requires that group health plans that provide coverage for "natural" children must provide the same coverage for adoptive children. The coverage should become effective when children are placed for adoption irregardless of whether or not the adoption has been finalized.

Other group health plans are subject to The Health Insurance Portability and Accountability Act of 1996, (HIPAA), which extends similar requirements to employers and plans not covered by ERISA.

Lastly, health plans not subject to either HIPPA or ERISA may still be subject to our Illinois Statute, which is clear that insurance companies may not exclude a child who is being adopted. The statute provides that insurance companies must permit the child to be added when:

1. The child is in the custody of the insured, pursuant to an interim court order of adoption or,
   (in the case of group insurance)
2. Placement of adoption, whichever comes first and gives temporary custody of the child to the insured adoptive parent(s) (See below for copy of relevant statutory provision)

ILLINOIS STATUTE ARTICLE XX ACCIDENT AND HEALTH INSURANCE

"215 ILCS 5/356h Sec. 356h. No individual or group policy of accident and health insurance which covers the insured's immediate family or children, as well as covering the insured, shall exclude a child from coverage or limit coverage for a child solely because the child is an adopted child, or solely because the child does not reside with the insured. For purposes of this Section, a child who is in the custody of the insured, pursuant to an interim court order of adoption or, in the case of group insurance, placement of adoption, whichever comes first, vesting temporary care of the child in the insured, is an adopted child, regardless of whether a final order granting adoption is ultimately issued. (Emphasis added) (Source: P.A. 91-549, eff. 8-14-99.)"

For your adopted children to be entitled to coverage under your employer's health insurance plan you must be a plan participant and you must otherwise be eligible to elect family coverage under the plan, and you must follow any other requirements for coverage under the plan.

Some insurance companies may argue that agency's placement papers are not sufficient to initiate adding the child to your insurance because a court did not issue them. You may need to explain to your insurance company that the court does not "place" children for adoption nor do they make "adoption placements" but agencies do. Hence, the legislation's specific language distinguishing children who are in custody "pursuant to an interim court order or placement of adoption". I argue that if the legislature intended the statute to mean "court ordered placement of adoption" it would have written it that way instead of using the words "or placement".

Agencys can and do grant temporary custody to adoptive parents through legally valid placement agreements. These instruments obligate prospective adoptive parents to be responsible for the child's medical health and to consent to all major medical procedures. I maintain that the reason the statute distinguishes between an interim order (which is the instrument that is first entered into when clients make their first appearance in court) is because the legislatures and parties to adoption proceedings know that adoptive placements are made prior to going into court. Most often adoptive placements are made weeks prior to going into court for the interim order.

You should address these issues in writing and go up the chain of command and deal directly with supervisors, etc. I recommend you fax letters as well as mail them to expedite matters. If you receive a denial letter, request an appeal immediately. Retain counsel if needed.

Infertility is a condition that strikes hundreds of couples in Illinois. Illinois law requires group insurance plans and health maintenance organizations (HMOs) to provide coverage for infertility. Here are the basic facts about the law.

Who Must Offer the Coverage?
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. However, for HMOs, the law does apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois. To determine if your HMO provides infertility benefits, you should contact the HMO directly or check your certificate of coverage.

Who is Covered?
To receive infertility coverage, you must:

• live in Illinois
• be covered by a fully insured Illinois group policy through an employer with more than 25 employees
• have been unable to conceive after one year of unprotected sexual intercourse between a male and female or have been unable to sustain a successful pregnancy

What is Covered?
Illinois requires group insurance and HMO plans to cover the diagnosis and treatment of infertility the same as all other conditions. For example, they may not apply any unique co-payments or deductibles for infertility coverage. Benefits shall include, but not be limited to:

• testing
• prescription drugs
• artificial insemination
• invitro fertilization (IVF)
• gamete intrafallopian tube transfer (GIFT)
• intracytoplasmic sperm injection (ICSI)
• donor sperm and eggs (medical costs)

What are the Limits?
Benefits for advanced procedures such as IVF, GIFT, ZIFT or ICSI are required only if you have been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy.

The benefits for advanced procedures required by the law are 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 successful 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, only one procedure (IVF, GIFT, ZIFT, or ICSI) 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 medical services rendered to a surrogate for purposes of childbirth; however, medical expenses incurred by a surrogate for infertility related services must be covered
• costs of preserving and storing sperm, eggs and embryos
• costs for an egg or sperm donor which are not medically necessary; any fees for non-medical services paid to the donor are not covered under the law
• experimental treatments
• costs for procedures which violate the religious and moral teachings or beliefs of the insurance company or covered group

For More Information
Call the State of Illinois, Department of Insurance Consumer Services Section at (312) 814-2427 or the State of Illinois, Office of Consumer Health Toll Free at (877) 527-9431 or visit them on their website at www.ins.state.il.us