"The opinions expressed in this article are those of the authors, and do not necessarily represent the position of The American Fertility Association."
by New Life Agency
It does not take a crystal ball to see that everyone involved in the infertility marketplace – from healthcare providers and insurance companies to the legal profession – are facing momentous changes when the 2014 Affordable Health Care Act kicks in.
Rumors abound about the coming changes, and one of the most pervasive – and potentially damaging to hopeful parents – is that in 2014 everyone will be able to have a baby for free. Parents are being told that major medical plans nationwide will magically pay for every surrogate pregnancy, every surrogate birth and every surrogate newborn.
Simply put, it’s not going to happen.
“Essential” Health Benefits: the heart of the Affordable Health Care Act
The new health care reform is intended to ensure that all Americans have access to “Essential Health Benefits.” While Maternity and Newborn Care is one of the 10 broad benefit categories, it’s a huge stretch to assume that surrogacy coverage is included. (It may be telling that “oral and vision care” is singled out under pediatric services, but infertility care is not even mentioned in the same breath as maternity and newborn care.)
While childless parents will certainly disagree, some argue that ART is not a medical necessity: It’s not “essential” to have a child in order to live. Keep in mind that only 15 states consider assisted reproduction services “essential” enough to mandate coverage. And when they do, it is severely limited with a possible threat to eliminate the coverage altogether in the next two years. The Affordable Care Act is leaving much of the details defining “essential” coverage to the states. For example, it may be left to the state exchanges to decide whether insurance coverage for autism will be included, and what limits will apply.
High costs, at a time when costs are center stage
The first salvo in the attack on surrogacy coverage is undoubtedly the issue of cost. When the first “test tube” baby was born in 1978, so was a new medical specialty. Of the 62 million women in the U.S. of childbearing age, 12% – or 1 in 8 couples – have sought medical assistance for fertility issues. With the advances in technology, IVF is steadily increasing in popularity, growing by 230% between1996 and 2008 (CDC Reports).
The science of infertility is complex and, therefore, expensive.
- ART-related pregnancy expenses add an average of 30% to pregnancy medical costs.
- Since multiple embryos are often implanted to increase the chances for success, there is greater likelihood of multiple births – added risk for mother and babies alike.
- Statistics confirm that IVF pregnancies are high-risk compared to normal pregnancies – but actual maternity costs are insignificant when weighed against newborn medical costs in the event infants have medical conditions.
But cost is not the only issue.
A third-party contract
Think about it. A surrogacy is a third-party pregnancy in which the surrogate is being compensated to have a baby for someone else. How many Americans want their tax dollars to pay someone thousands of dollars to have someone else’s baby? While some may argue that this is about a woman’s right to choose, it really is about who is going to pay for it. And if she is getting paid for a pregnancy, the general consensus will be that she should bear the cost, not the taxpayers. Insurers are not obligated to pay for third-party claims. For example, even when it comes to organ procurement and transplant, there is limited coverage available. There is no legal responsibility for any traditional U.S. insurer to recognize any person other than their Members.
Surrogacy coverage – or exclusion – MUST be defined!
In preparation for 2014, we must clarify, on a state and federal level, the Essential Health Benefits outlined in the Affordable Care Act. The Institute of Medicine published a report at the request of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services on Defining and Revising An Essential Health Benefits Package For Qualifying Health Plans. It is asserted that the lack of health insurance is harmful to health, and equal access of health care is needed. However the question still remains: How do insurers go about choosing what to include and what to exclude in an essential health insurance plan?
In reviewing this published information and how it is defining Surrogacy and Reproductive Services, it is unconscionable to have innocent gestational carriers believing their coverage will pay for their compensated pregnancy, only to find out after they are pregnant – or even worse, after they give birth – that, in-fact, the gestational carrier’s compensated pregnancy is excluded.
The Institute of Medicine committee found several insurers’ specific analysis of their products helpful.
Examples of Definitive Exclusions:
- WellPoint small group market benefits writing says their Standard Plan Exclusions are:
“Services related to Surrogacy — Exclude services related to surrogacy. Exclude all assisted reproductive technologies ART and the associated diagnostic testing and Rx treatments to support ART-EX-AI, IVF, ZIFT, GIFT.”
- The Federal Employees Health Benefits (FEHB) program developed a short list of general exclusions nationwide for both fee-for-service and managed care plans. This specifically included sampling of Cigna, UH, and WellPoint Anthem Blue Standard small business plans, with variations in the exclusion language:
“Surrogate parenting, services related to surrogacy, and Services related to conception, pregnancy or delivery in connection with a surrogate arrangement. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child.”
These plans might choose alternative wording for this exclusion: “In situations where you receive monetary compensation to act as a surrogate, health plan will seek reimbursement of all charges for covered services you receive that are associated with conception, pregnancy and/or delivery of the child. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child.”
THE ALARMING CHANGE HERE IS THE LANGUAGE IS NOT A LEIN TAKING ONLY THE COMPENSATION OF THE SURROGATE BUT MAKING HER PAY ALL CHARGES ASSOCIATED WITH THE PREGNANCY AND DELIVERY.
- Rosemary Lester, Business Project Manager at CIGNA Corporation, San Francisco CA, confirmed: For all definitions above Cigna explicitly excludes or otherwise does not cover.
- Sam Ho, Chief Medical Officer of United Healthcare and Executive Vice President of United Healthcare, Group INC confirmed: UH Excludes the same above.
- Ruth Raskas Vice President of Clinical Health Policy at WellPoint, confirmed: Although the exclusion language did not match their own; WellPoint says services provided to an individual (surrogate) not covered under the plan are not covered.
ACROSS ALL LINES OF THE INSURERS, REPRODUCTIVE SERVICES FOR IVF, GIFT, ZIFT, ART, DONOR CHARGES AND SERVICES, CRYO PRESERVATION, REVERSAL OF VOLUNTARY/ELECTIVE STERILIZATION WERE EITHER “explicitly excluded“ OR “excluded and not covered” BY MOST PLANS, EXCEPT AS REQUIRED BY MANDATED STATES.
More Definitive Exclusions:
- The Managed Risk Medical Insurance Board (MRMIB) solidified Exclusion Benefits related to surrogacy through regulation changes:
- ER-5-11-Title-10-Chapter 5.6 State-funded program, AIM (Access for Infants and Mothers) and
- ER-6-11-Title-10-Chapter 5.5 State-funded program, Major Risk Medical Insurance Program (MRMIP)
- (Both Programs excluding Maternity Care for a subscriber who has entered into an agreement to serve as a paid surrogate mother effective February 1, 2012.)
The California Medical Association concurred with the changes.
WHAT WE DON’T KNOW IS IF THE STATE’S ASSERTIVE EXCLUSIONARY CHANGES WILL FLOW TO THE FEDERAL LEVEL.
If we want these insurers to provide coverage for “Services related to Surrogacy,” we must start talking more about the intended parents and how they must be identified as the financially responsible party specifically within the insurance policy. Insurance must cover this as a third-party liability or exclude the coverage. The insurer must acknowledge prior to a pregnancy that there is a third party liable. Then the IP has the right to file a claim against an insurer on behalf of the surrogate/member if there is a dispute on medical benefits.
Otherwise the writing is clearly on the wall.
With Medical Necessity as the key focus, insurance underwriting departments are reviewing claims like never before – for everything from ultrasounds to infertility. It is becoming more and more evident that the infertility marketplace will require specialized insurance solutions.
A considerable number of non-U.S. citizens are under the impression that their surrogacies will be paid for under the Affordable Care Act. Not only is surrogacy not covered in most countries with nationalized insurance, surrogacy is actually illegal in many countries. While surrogacy is embraced in the U.S. as a means for couples struggling with infertility to achieve their dream of building a family, as a third-party contractual agreement it won’t be covered for U.S. citizens, let alone citizens of other countries.
To believe, assert, or even to advise as a surrogate professional that a foreign-national newborn in the U.S. will receive coverage – not to mention, to “don’t-ask-don’t-tell” and add the newborn as a dependent of the surrogate’s – is negligible at best, and fraudulent at worst.
The bottom line
Until all the uncertainty surrounding surrogacy and the Affordable Health Care Act is resolved, members of the infertility industry need to stop telling parents that they will have major medical coverage in 2014 – and parents should not blindly proceed as if they will. The risk is simply too great. “Essential Benefits” need to be definitively defined, and this will be an evolutionary process for years to come.
Call your traditional Major Medical representative today. Ask what policies they have available that will cover surrogacy pregnancy and delivery under the Affordable Health Care Act – and listen carefully to the answers you get.
All they really know is that THEY SIMPLY DON’T KNOW.
If anything, the need for Assisted Reproduction Insurance will be even more profound when the Affordable Health Care Act takes effect in 2014.
The American Fertility Association thanks New Life Agency, Inc. for providing the content for this article.