Oona Tempest / Kaiser Health News
After years of unsuccessfully trying for a 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. Yet the couple’s insurance, from Pritt’s job at an energy company, did — putting them among the lucky minority of Americans whose insurance plan covers the expensive fertility procedure. Kaminski and Pritt calculated what their share of the cost would be for an IVF cycle: $2,700, the maximum paid out under their policy.
Instead, after many twists and turns with two specialty practices, they paid over $15,000 for two cycles of IVF, including all medications. And, as is the case with the majority of procedures nationwide (success rates range from 12% to 49% depending on the age of the patient), neither step resulted in a pregnancy. viable. “It’s all been a nightmare,” said Kaminski, 37, who does freelance marketing and writing. “The stress has been unbelievable.”
About 1 in 5 women struggle to get pregnant, and IVF has become a common route to parenthood for many. But even if the demand increases, the insurance cover remains limited. About 27% of companies with 500 or more employees covered IVF in 2020, up from about 24% in 2015, according to Mercer, a consulting firm.
“Infertility is a disease and should be treated as such, and insurance coverage should take this into account,” said Dr. Kara Goldman, associate professor of obstetrics and gynecology at Northwestern University. “Coverage is often incomplete because too often people don’t see infertility as equal to other illnesses.”
Kaminski’s insurer, Blue Cross and Blue Shield of Illinois, offered a list of in-network IVF providers near the couple’s home in Melbourne, Florida. For in-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 networking specialists they tried, in the spring of 2020, had an office nearby in Viera, Florida. But after seeing the doctor, they learned they had to travel 3.5 hours to Miami, where the doctor performed the IVF procedures over three separate periods. visits.
The couple paid around $2,700 out of pocket for the drugs alone. 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 network of Blue Cross providers. It was in Winter Park, Florida, about an hour’s drive from their home.
Kaminski visited doctors at the Center for Reproductive Medicine and they scheduled him to start the procedure at their facility in the same building. But this establishment, the Orlando Avenue Surgery Center, was not part of the Blue Cross network.
Kaminski said the surgery center told her he was likely to be added to the Blue Cross network soon, and she asked the insurer for a waiver to have the center’s care considered part of the network. The insurer’s customer service agents told her she would get the waiver, but she did not get written confirmation. Still, she followed the procedure.
This took place in 2021 and Kaminski again expected to shell out around $2,700 for care from the IVF specialist in Winter Park. She knew she would face separate charges for the drugs used in IVF.
But because her care was deemed out-of-network by Blue Cross, Kaminski said, she was billed more than $6,000 by the clinic and its surgery center. This was in addition to nearly $4,000 in reimbursable drug costs.
Kaminski spent nearly a year trying to get Blue Cross to treat her second round of IVF as in-network. She said it was unfair that Blue Cross listed 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 surgery center is owned by some clinic doctors.
In a statement to KHN, the executive director of the Center for Reproductive Medicine, Stephen Brown, did not specifically address Kaminski’s case, although she had given him permission to discuss it. In an email, Brown wrote that the clinic was transparent with all of its patients and that its surgery center was not part of the Blue Cross network.
Brown said low reimbursement rates aren’t what kept the surgery center away from the Blue Cross network. Instead, he said, the insurer did not act quickly, taking more than four years to add the surgery center to its provider network. “The reason for not initially networking with BCBS was purely based on BCBS’s lack of response,” Brown said.
Prior to any treatment, Brown said, the clinic gives its patients cost estimates for their procedures based on their insurance. Kaminski received an estimate that she could expect to pay $3,000 to $4,000 just to transfer the lab-grown embryos to her womb.
In March 2021 – about a month after Kaminski completed treatment – the Winter Park Surgery Center was added to Blue Cross’ provider network.
In February 2022, KHN contacted the supplier and the insurer. Within two weeks, Blue Cross told the couple that he would consider all of the services they received at the surgery center into the network, and he paid all of his bills in full. Kaminski and Pritt no longer owed anything to the center. Blue Cross originally said it would pay a nominal portion of the disputed bills that totaled $21,450 for care in 2020 and 2021 because the surgery center was out of the network.
Blue Cross also confirmed to the couple that in January 2021 it granted them a waiver so that all bills from the surgery center could be considered part of the network. By mistake, the waiver had not been applied, so they faced high out-of-network charges.
“It finally makes sense,” Pritt said after learning their billing dispute had been resolved. “It’s good to know that we won’t have any more bills.”
After Blue Cross decided to cover IVF in Winter Park, the couple received $1,600 from the Orlando Avenue Surgery Center.
John Simley, spokesman for Blue Cross and Blue Shield of Illinois, said, “With non-routine waivers, mistakes can happen. The good news is that they’re 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 end up with huge bills. In addition, the lists of network provider insurers are not always accurate. “It feels like a bait and switch,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
A new federal insurance law, the No Surprises Act, came into effect in January 2022. It states that patients do not have to pay more than the in-network cost-sharing amount if the provider directory of the insurer provided inaccurate information.
It is unclear whether the law would apply in cases such as those of Kaminski and Pritt. Even if it was, the law came into force too late for them.
Betsy Campbell, head of engagement at Resolve: The National Infertility Association, a patient advocacy organization, said Kaminski’s case shows insurance coverage isn’t always designed around the patient. “The treatment of infertility is a series of very complex procedures involving laboratory work, surgery, anesthesia, and it must be provided in a way that the insurance system has not always respected. “, she said.
Too often, insurance forces a couple to take steps to get the care they need, Campbell said. “Everyone should have the right to have a family, and it doesn’t matter what employer you work for, what state you live in, or how much check you can write,” Campbell said.
Kaminski and Pritt aren’t giving up on having kids. For now, they are pursuing other fertility treatments that are not IVF.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).
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