Oona Tempest / Kaiser Health News
After years of trying to have an unsuccessful baby, Brenna Kaminski and her husband, Joshua Pritt, decided to try in vitro fertilization.
Only 15 states require insurance to cover fertility treatments, and Florida, where Kaminski and Pritt live, is not one of them. However, the couple’s insurance, of Pritt’s work in an energy company, did so, placing them among the lucky minority of Americans whose insurance plan covers the costly procedure of fertility. Kaminski and Pritt decided what their share of the cost would be for a round of IVF: $ 2,700, the maximum pocket according to their policy.
Instead, after many twists and turns with two specialized practices, they paid more than $ 15,000 for two rounds of IVF, including all the drugs. And, as is true for most procedures nationwide (success rates range from 12% to 49% depending on the patient’s age), neither round resulted in a viable pregnancy. “It’s all been a nightmare,” said Kaminski, 37, who specializes in marketing and freelance writing. “The stress has been amazing.”
About 1 in 5 women has problems getting pregnant and IVF has become a common path to fatherhood for many. But as demand grows, insurance coverage remains limited. About 27% of companies with 500 or more employees covered IVF in 2020, compared to 24% in 2015, according to Mercer, a consultant.
“Infertility is a disease and should be treated as such, and insurance coverage should reflect that,” said Dr. Kara Goldman, an associate professor of obstetrics and gynecology at Northwestern University. “Coverage is often incomplete because people often don’t see infertility as equal to other illnesses.”
Kaminski’s insurance company, Blue Cross and Blue Shield of Illinois, offered a list of in-network IVF providers near the couple’s home in Melbourne, Florida. For network care, the couple would be responsible for 20% of the costs. For out-of-network care, they would have to pay 40%.
The first network specialists they tested, in the spring of 2020, had a nearby office in Viera, Florida. But after seeing the doctor, they learned that they had to travel 3 and a half hours to Miami, where the doctor performed IVF procedures during three different procedures. visits.
The couple paid about $ 2,700 out of pocket for the drugs alone. They also paid an additional $ 500 because the fertility clinic forced them to use an out-of-network lab to do blood tests.
In November 2020, the couple decided to try again, with another fertility medical group in their network of Blue Cross providers. He was in Winter Park, Florida, an hour’s drive from his home.
Kaminski visited the doctors at the Center for Reproductive Medicine and scheduled her to begin the procedure at her facility in the same building. But this facility, the Orlando Avenue Surgery Center, was not on the Blue Cross network.
Kaminski said the surgery center told him it was likely to be added to the Blue Cross network soon and asked the insurer for an exemption for the center’s care to be considered within the network. The insurer’s customer service agents told her she would receive the exemption, but did not confirm this in writing. However, he continued with the procedure.
It took place in 2021, and Kaminski again expected to pay about $ 2,700 out of pocket for the care of the IVF specialist in Winter Park. He knew he would face separate pocket costs for the drugs used in IVF.
But because the Blue Cross considered his care to be offline, Kaminski said, the clinic and its surgery center billed him more than $ 6,000. That added up to about $ 4,000 in out-of-pocket drug costs.
Kaminski has spent almost a year trying to get the Blue Cross to treat its second round of IVF as in-network. He said it was unfair for the Blue Cross to include the Winter Park Fertility Clinic in its network of providers if its doctors performed the actual IVF procedure at an out-of-network surgery center. The surgical center is owned by some of the clinic’s doctors.
In a statement to KHN, the executive director of the Center for Reproductive Medicine, Stephen Brown, would not specifically address Kaminski’s case even though she had given him permission to speak. In an email, Brown wrote that the clinic was transparent with all its patients that its surgery center was not in the Blue Cross network.
Brown said the low reimbursement rates are not what has kept the surgery center out of the Blue Cross network. However, he said, the insurer did not act quickly, and it took more than four years to add the surgery center to its network of providers. “The reason for not initially networking with BCBS was based solely on BCBS’s lack of response,” Brown said.
Before doing any treatment, Brown said, the clinic offers its patients estimates of the costs of their procedures based on their insurance. Kaminski received an estimate that he could expect to pay between $ 3,000 and $ 4,000 just for the transfer of laboratory-grown embryos to his uterus.
In March 2021, about a month after Kaminski completed his treatment, the Winter Park Surgery Center was added to the Blue Cross provider network.
In February 2022, KHN contacted the supplier and the insurer. In two weeks, Blue Cross told the couple that they would consider all the services they received at the surgery center within the network and that they paid all their bills. Kaminski and Pritt no longer owe anything to the center. The Blue Cross had initially said it would pay a nominal portion of the disputed bills amounting to $ 21,450 for care in 2020 and 2021 because the surgery center was off-grid.
The Blue Cross also confirmed to the couple that in January 2021 they had been granted an exemption so that all bills from the surgical center could be considered within the network. By mistake, the resignation had not been implemented, so they faced high off-network charges.
“It finally makes sense,” Pritt said after learning that his billing dispute had been resolved. “It’s good to know we won’t get any more bills.”
After the Blue Cross decided to cover IVF in Winter Park, the couple received $ 1,600 from the Orlando Avenue Surgery Center.
John Simley, a spokesman for the Blue Cross and Blue Shield of Illinois, said: “With non-routine exemptions, mistakes can occur. The good news is that they are usually fixed quickly.”
In this case, however, it took almost a year.
Experts say Kaminski’s case shows that even when people have IVF coverage, they can be left with huge bills. In addition, the lists of providers in the network of insurers are not always accurate. “It looks like a bait and switch,” said Sabrina Corlette, a research professor and co-director of the Georgetown University Health Insurance Reform Center.
A new federal insurance law, the Unsurprising Act, went into effect in January 2022. It says patients should pay no more than the amount of the share in network costs if the provider directory the insurer gave inaccurate information.
It is unclear whether the law would apply in cases such as Kaminski and Pritt. Even if they did, the law came into force too late for them.
Betsy Campbell, engagement director for Resolve: The National Infertility Association, a patient advocacy organization, said Kaminski’s case shows that insurance coverage is not always designed around the patient. “Infertility treatment is a series of very complex procedures that involve laboratory work, surgery, anesthesia, and must be provided in a way that the insurance system has not always complied with,” he said.
Too often, insurance makes a couple jump through hoops to get the attention they need, Campbell said. “Everyone should have the right to start a family, and it shouldn’t matter what employer you work for, or what state you live in, or the big check you can write,” Campbell said.
Kaminski and Pritt do not give up having children. At the moment, they are doing other fertility treatments other than IVF.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an operating program independent of the publisher KFF (Kaiser Family Foundation).
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