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The Hidden Costs Of Fully Covered Infertility Treatment

Discussion in 'Hospital' started by The Good Doctor, Apr 27, 2022.

  1. The Good Doctor

    The Good Doctor Golden Member

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    After years of searching for answers to my pain, I was finally diagnosed with endometriosis during my second year of medical school. However, the joy of finally having a diagnosis quickly became overshadowed by the knowledge that I was now a part of the 1 in 4 female physicians who suffer from infertility. As a married 27-year-old future doctor with at least six more years of training, I knew that having children was not financially nor reasonably possible if I was to complete my medical training. However, my biological clock was coming to a rapid end, and I needed to make drastic plans to preserve my fertility if I ever wanted the opportunity to have biological children in the future.

    Before even meeting with a fertility specialist, the first step was to call my medical school-provided health insurance to determine if fertility treatment was covered under our current plan. To our relief, the majority of the billing codes we provided were covered under our PPO plan:
    • Fertility testing: “no restrictions”
    • Testing coverage: “yes”
    • Fertility treatment: “yes, depends on code”
    • Intrauterine insemination (IUI) coverage: “no”
    • In vitro fertilization (IVF) coverage: “yes”
    • Lifetime or yearly limits for fertility treatments: “4 per contract year”
    • Does insurance require prior authorization before treatment begins? “no”
    • Infertility medication coverage: “yes”
    • Fertility preservation: unknown
    • Any exclusions for egg retrieval: unknown
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    Since everything seemed good to go, I began a very long process of infertility medical treatment, which included a long fight to acquire the injectable medications required for ovarian follicle stimulation.

    I spent hours having back and forth conversations with the insurance and the specialty pharmacy throughout the rest of the year. Unfortunately, only half of my fertility medications were covered. Particularly five medications, because they were “injectable not by a provider,” were not covered under pharmaceutical benefits. These medications were: Lupron (J9217), Ganirelix (SO132), Follistem (SO128), Novarel (JO725), Menopur (SO122). The total out-of-pocket cost would be over $10,000 for just one cycle of follicle stimulation.

    However, they were possibly covered under medical benefits. Therefore, I submitted an authorization requiring more hours to acquire health records from multiple providers. Unfortunately, this prior authorization was denied.

    That summer, I decided to take a leave of absence (LOA) from medical school because I struggled to deal with all of the medical and insurance stress while also trying to study for my Step 1 board exam. My school gave me the option of continuing my health insurance during my LOA for a premium total of $3,000. Since, according to the insurance provider, my infertility medical treatment was covered, I decided to stay with this insurance while also applying for Medicaid. Thankfully, after many months, my caseworker for the specialty pharmacy was able to get the five injectable medications approved!

    That fall, I went through an ovarian follicle stimulation cycle which included daily injections, weekly blood tests, and ultrasounds, despite the extreme physical pain from the increased hormones impacting my endometriosis. After three weeks of injections, I was able to get my follicles removed. My doctor highly recommended that we go ahead and fertilize the eggs since they had a greater chance of later success since we were freezing them until after residency. We were able to fertilize five eggs, but only one embryo was successful and able to be frozen.

    We then received a bill from the hospital saying that the insurance had paid around $11,000 for the procedure, Medicaid paid $0, and I owed $2,500. The insurance explained that I am required to pay 20 percent up to my $8,000 out of pocket. In addition, they do not cover embryo freezing, just egg freezing. Therefore, just like I had successfully done previously with my endometriosis surgery, I applied for financial aid through the hospital.

    Months later, I received a call from the hospital that I was denied the financial assistance which is provided to individuals below the poverty line. Their reason for the denial was that infertility treatment “was a choice.”

    This “fully covered” fertility treatment led me to owe an additional $3,000 for my insurance premium, $350 for copays, and $2,500 for the follicle removal and freezing procedure. This unexpected expense would total over four times our monthly rent.

    Looking to the future, since I only froze one embryo and my ovary reserve is diminishing, we are hoping to go through another infertility treatment cycle. Although, once again, the medications are once again being denied.

    Infertility is just like any other mental or physical health condition and should be fully covered, including pharmaceutical, medical, and surgical treatment. As data suggests, 1 in 4 female physicians will experience infertility, which is twice the general population’s rate, which is 1 in 8 women. The reasons for the increase in infertility include significant stress levels during the education and profession, deferred family planning, and long hours of medical careers. Like myself, Black and Latinx women have higher risks of experiencing infertility, not explained by biological differences but by social inequalities and disparities in health.

    Lastly, even though the Illinois Mandate requires that companies provide comprehensive fertility coverage in health care insurance. Fertility coverage still has much to improve for all individuals to receive truly “fully covered” fertility testing, treatment, and support.

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