Shorter version published on KevinMD.com: "The hidden costs of fully covered infertility treatment"
Let’s start from the beginning, during my fall semester of my second year of medical school when I was finally diagnosed with endometriosis, anxiety, and infertility.
After determining I most likely had endometriosis, my doctor was able to schedule me for a surgery. The surgery took place during my Thanksgiving break. The final bill for me to pay was around $6000. At this point I wasn’t aware I could increase my loans for medical expenses. Therefore, I applied for a financial assistance through the hospital which was offered to individuals who are under the poverty line. My husband and I were both medical students, and did not have a job nor family financial support to cover these medical expenses. We both take out 100% of our living expenses through loans. Requesting financial support from the hospital took many weeks of back and forth phone calls and emails. Months later I was notified that the hospital would fully fund the rest of my surgery bill. That was one of the best news I had received from the whole situation. However, the surgery had confirmed I had endometriosis which included infertility. The surgeon recommended I reach out to a fertility doctor at my hospital to begin infertility testing and treatment.
The first steps before we could even see the doctor was to call our school required and provided health insurance to determine what was and was not covered under our current plan. To everyone’s relief the majority of the codes we provided were covered under our PPO plan:
Fertility Testing: (Diagnosis Code: Z31.41) - “no restrictions”
Testing Coverage?(CPT:76856,76857,74740,76830,76831,58340) - “yes”
Fertility Treatment: (Diagnosis Code(s): N97.9, Z31.83) - “yes, depends on code”
IntrauterineI Insemination (IUI) Coverage?(CPTCode:58322) - “no”
In Vitro Fertilization (IVF) Coverage? (CPT:58970,58974) - “yes”
Life time or yearly limits for fertility treatments? - “4 per contract year”
Does insurance require a prior authorization before treatment begins? - “no”
Infertility medication coverage? - “yes”
Fertility Preservation (Diagnosis Code(s): Z31.62, Z31.84) - unknown
Any exclusions for Egg Retrieval CPT58970 - unknown
Since it seemed that everything was good to go I began a very long process of infertility medical treatment, which included a long fight to acquire the medications required for treatment.
In spring and summer of 2021 I spent around 4 hours a day, multiple times a week, having back and forth conversations with the insurance and the speciality pharmacy. Apparently only half of my fertility medications were covered. Particularly there were five medications, that “since they are injectable fertility medications” were not covered under pharmaceutical benefits. These medications were: Lupron (J9217), Ganirelix (SO132), Follistem (SO128), Novarel (JO725), Menopur (SO122). In total, the out of pocket cost would be over $10,000 for just one cycle of ovarian stimulation.
After hours of back-and-forth on the phone, I was able to submit a prior authorization under my medical benefits, which required more hours of acquiring health records and documentations from multiple providers. This prior authorization was denied, which turned into an appeal, which was also denied. Interestingly all but two of these medications are indicated that they are covered under the medications as part of our plan: https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021211s011lbl.pdf
In June, I decided to take a leave of absence (LOA) from medical school because I was struggling to deal with all of the medical stress while also trying to study for my step1 board exam. The school’s Financial Affairs gave me the option of continuing my health insurance during my leave of absence with our PPO insurance. They told me it was going be about $3000 total for the Fall and Spring term. Since according to the insurance provider, my infertility medical treatment and mental health services were covered, I decided to stay with the insurance.
To note, since I took the LOA in the middle of the Summer term, I had to pay back the majority of my living expense loans of $8000 to the federal government. This unexpected expense led us to not have any money for rent, food, medications and co-pays. Therefore, I actively acquired three different part time jobs, applied for COVID Emergency student assistance, utility assistance, Medicaid, food stamps, sold our car, and moved to a cheaper rental. Each of these applications took additional hours away from studying, but this is what had to happen to prevent becoming evicted or going hungry.
The day after my board exam I once again began the back and forth phone calls to the pharmacy and my fertility provider to continue the request for my infertility medication treatment. Finally, after over 50+ hours of phone calls and waiting on hold, my caseworker for the speciality pharmacy was able to get the five medications approved! We were ecstatic!
In October and November I finally went through an ovarian follicle stimulation cycle. This included daily injections, weekly blood tests, ultrasounds, notwithstanding the extreme physical pain which prevented me from working full hours. In November 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 we finished residency. We were able to fertilize 5 eggs, but only 1 embryo was successful and able to be frozen.
Then in December we received a bill from the hospital saying that the insurance had paid around $11,000 for the surgery, Medicaid paid $0, and I owed $2500. The insurance reasoning is that I am required to pay 20% up to my $8,000 out of pocket. In addition, they do not cover embryo freezing, just egg freezing. Therefore, just like I had done previously on my endometriosis surgery I applied for financial aid through the hospital. Even though I was working part time we could still not afford this bill.
As we waited for financial aid from the hospital I ended up figuring out that I failed my board exam and had to retake it. In January and February I studied and retook the exam while also working part time as a medical assistant and as a fitness instructor. At the beginning of March, I received a call from the hospital that I was denied financial assistance. I was very shocked because on their website it says that they assist people below the poverty line and I was making less than $20,000 a year. However, they said that since infertility treatment “was a choice” they were not going to financially assist me. I then called the insurance to figure out what was going on because it was our understanding that 100% of the treatment and surgery was covered. However, they responded that this was my 20% that I was supposed to cover and they were going to pay 80% until I hit the $8000 out of pocket max. That being said, $8,000 is 4 times our monthly rent.
To summarize this 9 month leave of absence from medical school with fertility treatment led me to owe $3000 for my insurance premium, $350 for medication copays, and $2500 for the follicle removal and freezing procedure.
Looking forward, since I only got one embryo, and my ovary reserve is diminishing with my medical condition, we are hoping to go through another infertility treatment cycle. Although, once again according to our insurance and the new speciality pharmacy the fertility meds are not covered, and are once again getting denied. These five injectable medications cost $10,000 and are not included in the insurance's out of pocket allowance. So we are back where we began nine months ago.
Infertility is just like any other mental or physical health condition and should be fully covered specifically in regards to pharmaceutical, medical, and surgical treatment. As data suggests 1 in 4 female physicians will experience infertility which is twice the rate of the general population, which is 1 in 8 women. The reasons for the increase in infertility include high educational and work stress, differed family planning, and long hours of medical careers. Minority and colored women, like myself, have even higher rates of infertility because of various social and health inequities.
A common myth is that the full fertility coverage benefit will increase premium costs. However, comprehensive infertility coverage can be provided at less that 1% of total premium cost. In addition, IVF only accounts for less than 3% of infertility services used because most can be covered through medications (which is currently not covered in our PPO plan) or through surgery.
Q&A positioned to my Graduate Institution & Insurance Company:
Q: Why doesn’t our “fully covered” fertility benefit cover fertility medications?
A: It should under IL mandate: https://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=021500050K356m
Q: Why doesn’t our infertility benefit cover embryo preservation, when it does cover egg preservation?
A: “Benefits follow the Illinois State Mandate and Embryo. Preservation is not covered on the IL Mandate.”
Q: Why is our "out of pocket" $8,000 when medical students receiving loans (less than 55% of medical students) do not have this amount allocated in their living expenses (our school distributes to us about $14,000/semester)?
A: Each school and insurance company sets the term amounts. Students receiving federal loans can increase their loan amount each year for "unexpected medical expenses" (including this out of pocket max). However, they must pay for it first (using a credit card or money they have) and then provide a reciept and submit an increase of loan request.
IL Infertility Mandate: https://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=021500050K356m
AMWA-RESOLVE Coverage At Work Toolkit:
RESOLVE Fertility Survey Final Report
FAQ Quick Facts About Infertility, The Society of Reproductive Surgeons
Average Medical Student Debt in 2021 by Race, Gender, Etc
Shahriar AA, Puram VV, Miller JM, et al. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open. 2022;5(3):e222621. doi:10.1001/jamanetworkopen.2022.2621