Phil Galewitz, Kaiser Health News
Brenna Kaminski and her husband, Joshua Pritt, decided to try IVF after years of trying unsuccessfully to have a baby.
only 15 states requires insurance to cover fertility treatments, and Florida, where Kaminski and Pritt live, is not one of them. Still, the couple’s insurance for Pritt’s job at an energy company put them among the lucky few of Americans whose insurance plan covers the expensive fertility procedure. Kaminski and Pritt calculated what their share of the cost for a round of IVF would be: a maximum of $2,700 out-of-pocket according to their policy.
Instead, after many twists and turns with the two specialty practices, they paid over $15,000 for two rounds of IVF including all drugs. And as it is true for most of the procedures nationally (success rates range from 12% to 49% depending on the age of the patient), neither round resulted in a viable pregnancy. “This whole thing has been a nightmare,” said Kaminski, 37, a freelance marketing and writer. “The stress was incredible.”
About 1 in 5 women She has trouble getting pregnant and IVF has become a common path to parenthood for many. However, even as demand increases, insurance coverage remains limited. About 27% of companies with 500 or more employees were covered by IVF in 2020, up from around 24% in 2015. according to Mercera consulting firm.
“Infertility is a disease and should be treated as such, and insurance coverage should reflect that,” she said. Dr. Black GoldmanAssociate professor of obstetrics and gynecology at Northwestern University. “Coverage is often lacking because people do not equate infertility with other diseases.”
Kaminski’s insurer Blue Cross and Blue Shield of Illinois have presented a list of in-network IVF providers near the couple’s home in Melbourne, Florida. For in-network maintenance, the couple will be responsible for 20% of the costs. They would have to pay 40% for off-grid maintenance.
The first in-network experts they tried in the spring of 2020 had an office nearby in Viera, Florida. But after seeing a doctor, they learned that they had to travel 3½ hours to Miami, where the doctor performed the IVF procedures on three separate visits.
The couple paid about $2,700 out of pocket for the drugs alone. They also paid an additional $500 because the fertility clinic required them to use an off-network lab for blood tests.
In November 2020 the couple decided to try again with another fertility medical group listed on their Blue Cross provider networks. He was in Winter Park, Florida, about an hour’s drive from their home.
Kaminski visited with the doctors at the Center for Reproductive Medicine and they planned to have the procedure started at their facility in the same building. However, this facility, Orlando Avenue Surgical 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 in the near future and applied to the insurer for a waiver to have the center’s care evaluated within the network. It was said that the insurer would be waived by their customer service agents, but this was not confirmed in writing. Still went through the procedure.
It happened in 2021, and Kaminski was expected to pay again about $2,700 out of pocket for the care of the IVF specialist in Winter Park. He knew he would face separate out-of-pocket costs for drugs used in IVF.
However, since her care was considered off-net by Blue Cross, Kaminski said she was billed more than $6,000 by the clinic and surgery center. This added to the out-of-pocket drug cost of about $4,000.
Kaminski spent nearly a year getting Blue Cross’s second round of IVF covered in-network. He said it was unfair that Blue Cross had listed the Winter Park fertility clinic on its provider network if its doctors were performing the actual IVF procedure at an out-of-network surgical center. The surgery center is owned by some doctors of the clinic.
The managing director of the Center for Reproductive Medicine told KHN, Stephen Brown, although he had allowed Kaminski to discuss the case, he would not discuss it privately. In an email, Brown wrote that the clinic is transparent to all patients and that the surgery center is not in Blue Cross’ network.
Brown said it’s not the low reimbursement rates that keep the surgery center out of the Blue Cross network. Instead, he said, the insurer didn’t act fast and it took more than four years to add the surgery center to its provider network. “The reason I wasn’t in the network with BCBS in the beginning was simply because BCBS wasn’t responding,” Brown said.
Before any treatment is given, the clinic estimates patients’ costs of their procedures based on their insurance, Brown said. Kaminski received an estimate saying she could pay $3,000 to $4,000 just for lab-grown embryos to be transferred into her womb.
In March 2021 – about a month after Kaminski completed his treatment – the Winter Park surgical center was added to the Blue Cross’ provider network.
In February 2022, KHN reached the provider and insurer. Blue Cross said that within two weeks, it will evaluate all the services they receive at the dual surgery center within the network and have paid all their bills in full. Kaminski and Pritt no longer owe the centre. Blue Cross had initially said it would pay a nominal portion of the disputed $21,450 bills for care in 2020 and 2021 due to the surgery center being off the grid.
Blue Cross also confirmed to the couple that it gave them a waiver in January 2021 so that all bills from the surgical center could be accepted within the network. Inadvertently, no waivers were applied, so they faced high out-of-network fees.
“It finally makes sense,” Pritt said after learning that the billing dispute had been resolved. “It’s good to know we won’t be getting any more bills.”
After Blue Cross decided to shut down IVF in Winter Park, the couple received $1,600 from Orlando Avenue Surgery Center.
John SimleyA spokesperson for Blue Cross and Blue Shield of Illinois said: “There can be errors in non-routine waivers. The good news is that they are usually fixed quickly.”
In this case, however, it took about a year.
Experts say Kaminski’s case shows that people can face huge bills even when they have IVF insurance. Also, insurers’ in-network provider lists are not always accurate. “It feels like a bait and a transition,” said Sabrina Corlette, research professor and co-director of the Georgetown University Center for Health Insurance Reforms.
A new federal insurance law, the No Surprises Act, went into effect in January 2022. He says that if the insurer’s provider guide gave false information, patients don’t have to pay more than the in-network cost-sharing amount.
It’s unclear whether the law will apply in cases like the Kaminski and Pritt cases. Even if he did, the law went into effect too late for them.
Betsy Campbell, chief engagement officer at Resolve: The National Infertility Association, a patient advocacy organization, said Kaminski’s case shows that insurance coverage isn’t always designed around the patient. “Infertility treatment is a series of very complex procedures that includes laboratory work, surgery, anesthesia, and needs to be provided in a way that the insurance system doesn’t always respect,” she said.
Too often, insurance causes a couple to go through hoops to get the care they need, Campbell said. “Everyone should have the right to start a family, and it shouldn’t matter what employer you work for, what state you live in, or how big a check you can write,” Campbell said.
Kaminski and Pritt are not giving up on having children. For now, they are pursuing other non-IVF fertility treatments.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with Policy Analysis and Polling, KHN is currently one of the three main operating programs. KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides information on health issues to the nation.
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