After years of trying unsuccessfully to have a baby, Brenna Kaminski and her husband Joshua Pritt decided to try in vitro fertilization.
only 15 states need insurance Fertility treatment is covered, and Florida, where Kaminsky and Pritt live, is not one of them. Still, the couple’s insurance, from Pritt’s job at an energy company, did — making them one of the lucky few Americans whose insurance plans cover expensive fertility procedures. Kaminski and Pritt calculated their cost-sharing over a round of IVF: $2,700, the highest out-of-pocket cost under their policy.
Instead, after multiple twists and turns in two professional practices, they paid more than $15,000 for two rounds of IVF, including all medications.Moreover, for most programs Nationwide (success rates ranged from 12% to 49%, depending on the patient’s age), both rounds were unsuccessful in pregnancies. “This whole thing is like a nightmare,” said Kaminsky, 37, who works in freelance marketing and writing. “The pressure is unbelievable.”
about one in five women Having trouble getting pregnant, IVF has become a common route for many. But even as demand grows, insurance coverage remains limited. By 2020, about 27% of companies with 500 or more employees covered IVF, up from about 24% in 2015, According to Mercera consulting firm.
“Infertility is a disease and should be treated as such, and insurance coverage should reflect that,” said PhD.Kara Goldman, Associate Professor of Obstetrics and Gynecology at Northwestern University. “Coverage is often incomplete because infertility is often not considered the same as other conditions.”
Kaminski’s insurance company, Blue Cross and Blue Shield of Illinois, provided a list of in-network IVF providers near the couple’s home in Melbourne, Florida. For in-network care, the couple will cover 20% of the cost. For out-of-network care, they must pay 40%.
In the spring of 2020, the first in-network experts they tried had offices near Vieira, Florida. But after seeing a doctor, they learned they had to travel 3.5 hours to Miami, where doctors performed the IVF procedure in three separate visits.
The couple only paid about $2,700 for the drug. They also paid an additional $500 because the fertility clinic required them to use an out-of-network lab for blood tests.
In November 2020, the couple decided to try again, with another fertility medical group listed in their Blue Cross provider network. It was in Winter Park, Florida, about an hour’s drive from their home.
Kaminsky visited doctors at the Center for Reproductive Medicine, who arranged for her to begin surgery at a facility in the same building. But that facility, the Orlando Avenue Surgery Center, is not in the Blue Cross network.
Kaminski said the surgery center told her it could soon be added to the Blue Cross network, and she called on insurers to drop the center’s care in the network. The insurance company’s customer service agent told her she would get a waiver, but she didn’t get written confirmation. Still, she completed the procedure.
It happens in 2021, and Kaminski again expects to pay about $2,700 out of pocket to get care from an IVF specialist in Winter Park. She knew she would face separate out-of-pocket costs for the drugs used in IVF.
But because Blue Cross thought her care was out of network, Kaminsky said the clinic and its surgery center charged her more than $6,000. And that doesn’t include nearly $4,000 in out-of-pocket drug costs.
Kaminski spent nearly a year trying to get Blue Cross to consider her second round of IVF as in-network. She said it would be unfair for Blue Cross to include Winter Park Fertility Clinic in its provider network if Blue Cross doctors performed the actual IVF procedures at out-of-network surgery centers. Surgery centers are owned by some doctors in the clinic.
In a statement to KHN, executive director of the Center for Reproductive Medicine, Stephen Brown, would not specifically address Kaminsky’s situation, even if she had given him permission to discuss it. In an email, Brown wrote that the clinic is transparent to all patients and that its surgery center is not in Blue Cross’s network.
Brown said low reimbursement rates are not what keeps surgery centers out of the Blue Cross network. Instead, he said, the insurer didn’t move quickly, and it took more than four years to add the surgery center to its provider network. “The reason there wasn’t a network with BCBS in the first place was purely because BCBS didn’t respond,” Brown said.
Before any treatment, the clinic estimates the cost of their surgery to patients based on their insurance, Brown said. Kaminsky received an estimate saying she may have to pay $3,000 to $4,000 to transfer the lab-grown embryos into her uterus.
In March 2021, about a month after Kaminski completed treatment, Winter Park Surgery Center was added to Blue Cross’s provider network.
In February 2022, KHN contacted suppliers and insurance companies. Within two weeks, Blue Cross told the couple it would consider all services they received at in-network surgery centers and paid all bills in full. Kaminsky and Plitt no longer owe the center anything. Blue Cross initially said it would pay the nominal portion of the disputed bill totaling $21,450 in 2020 and 2021 because the surgery center was not in its network.
Blue Cross also confirmed to the couple that in January 2021 it had granted them a waiver so all surgery centre bills could be considered in-network bills. By mistake, the waiver was not being applied, so they faced high out-of-network fees.
“It finally made sense,” Plitt said after learning their billing dispute was resolved. “It’s good to know we won’t be getting any more bills.”
The couple received a $1,600 refund from the Orlando Avenue Surgery Center after Blue Cross decided to do IVF at Winter Park.
John SimleyA spokesman for Illinois Blue Cross and Blue Shield said: “If there are extraordinary exemptions, errors can occur. The good news is that they are usually fixed quickly.”
In this case, however, it took almost a year.
Experts say Kaminsky’s case shows that even if people have IVF insurance, they can face huge bills. Additionally, insurers’ lists of in-network providers are not always accurate. “It felt like a bait and switch,” said Sabrina Collette, a research professor and co-director of Georgetown University’s Center for Health Insurance Reform.
A new federal insurance law, the No Accidents Act, goes into effect in January 2022. It stipulates that patients do not have to pay more than the in-network cost-sharing if the insurer’s provider directory provides inaccurate information.
Whether the law applies to cases such as Kaminsky and Pritt is unclear. Even so, it was too late for the law to take effect.
Kaminski’s case shows that insurance coverage isn’t always designed around the patient, said Betsy Campbell, chief engagement officer at patient advocacy group Resolve: The National Infertility Association. “Infertility treatment is a very complex series of procedures involving lab work, surgery, anesthesia and needs to be provided in a way that the insurance system doesn’t always respect,” she said.
Insurance often makes a couple jump ship to get the care they need, Campbell said. “Everyone should have the right to start a family, no matter what employer you work for, or what state you live in, or how big a check you can write,” Campbell said.
Kaminsky and Plitt haven’t given up on having children. Currently, they are seeking other fertility treatments other than IVF.
Bill of the Month is a crowdsourced survey KHN and NPR Analyse and explain medical expenses.
KHN (Kaiser Health News) is a national newsroom that provides in-depth news coverage on health issues.Along with policy analysis and polling, KHN is one of the top three operating programs in the U.S. KFC (Kaiser Family Foundation). KFF is a donating non-profit organization that provides information on health issues to the state.
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