Julie Appleby, KFF Health News
During her annual OB-GYN go to, Callie Anderson requested about getting off the contraception tablet.
“We decided the best option for me was an IUD,” she mentioned, referring to an intrauterine machine, a long-acting, reversible kind of contraception.
Anderson, 25, of Scranton, Pennsylvania, requested her physician how a lot it may cost. At the time, she was working in a U.S. senator’s native workplace and was lined below her father’s insurance coverage through a plan provided to retired state police.
“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson mentioned.
She mentioned she heard nothing extra and assumed that meant it was lined.
After ready months for an appointment, Anderson had the insertion process final March. She paid $25, her copay for an workplace go to, and every part went nicely.
“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she mentioned.
Then the invoice got here.
The Medical Procedure
According to Planned Parenthood, IUDs and implantable contraception represented nearly 25% of its contraceptive providers supplied from October 2021 to September 2022, per the most recent information out there.
There are two types of IUDs: copper, which Planned Parenthood says can defend in opposition to being pregnant for as much as 12 years, and hormonal, which might final from three to eight years relying on the model. Hormonal IUDs can stop ovulation, and each sorts have an effect on the motion of sperm, designed to cease them from reaching an egg.
A doctor or different practitioner makes use of a tube to insert the IUD, passing it by the cervix and releasing it into the uterus.
Doctors usually suggest over-the-counter medication for insertion ache, a priority that prompts some sufferers to keep away from IUDs. Last yr, federal well being officers really useful medical doctors talk about ache administration with sufferers beforehand, together with choices akin to lidocaine pictures and topical anesthetics.
The Final Bill
$14,658: $117 for a being pregnant check, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the physician’s providers.
The Billing Problem: A ‘Grandfathered’ Plan
Anderson bought a uncommon glimpse of what can occur when insurance coverage doesn’t cowl contraception.
The Affordable Care Act requires well being plans to supply preventive care, including a variety of contraceptives, with out value to the affected person.
But Anderson’s plan doesn’t should adjust to the ACA. That’s as a result of it’s thought-about a “grandfathered” plan, which means it existed earlier than March 23, 2010, when President Barack Obama signed the ACA into regulation, and has not modified considerably since then.
It’s unclear what number of Americans have such protection. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of lined employees have been nonetheless on “grandfathered” plans.
Anderson mentioned she didn’t know that the plan was grandfathered — and that it didn’t cowl IUDs — till she contacted her insurer after it denied fee. Her physician with Geisinger, a nonprofit health system in Pennsylvania, was in-network.
“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she mentioned.
Mike McMullen, a Geisinger spokesperson, mentioned in an electronic mail to KFF Health News that with most insurance policy, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”
He didn’t specify whether or not it’s the well being system’s coverage to hunt such authorizations for IUDs, nor did he touch upon the quantity charged.
The Pennsylvania State Troopers Association, which affords some retirees the plan that lined Anderson, didn’t reply to requests for remark. Highmark Blue Cross Blue Shield, the insurer, referred inquiries to the state.
Dan Egan, communications director for the state’s Office of Administration, confirmed in an electronic mail that the insurance coverage plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”
A benefit handbook for the plan identifies it as grandfathered and lists a wide range of excluded providers. Among them are “contraceptive devices, implants, injections and all related services.”
The $14,658 invoice, an quantity that sometimes can be negotiated down by an insurer, was solely Anderson’s accountability.
“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, mentioned Danika Severino Wynn, vice chairman for care and entry on the Planned Parenthood Federation of America.
Costs for IUDs range, relying on the sort, the place the affected person lives, insurance coverage standing, the supply of economic help, and extra medical components, Severino Wynn mentioned.
She mentioned most insurers cowl the units, however protection can range, too. For occasion, some cowl solely sure sorts or manufacturers of contraceptives. Generally, an IUD insertion prices $500 to $1,500, she added.
Many suppliers, together with Planned Parenthood, have sliding-scale charges based mostly on earnings or can arrange fee plans for cash-paying or underinsured sufferers, she mentioned.
According to FAIR Health, a value estimation instrument that makes use of claims information, an uninsured affected person within the Scranton space might count on to be charged $1,183 for an IUD insertion performed at an ambulatory surgical procedure heart or $4,319 in a hospital outpatient clinic.
The Resolution
Anderson texted and referred to as her insurer and Geisinger a number of instances, spending hours on the cellphone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in a single message with workers at her physician’s workplace.
She mentioned she felt rebuffed when she requested billing representatives about monetary help, even after noting the invoice was greater than 20% of her annual earnings.
“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she mentioned. The billing workplace, she mentioned, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”
Eventually, she was put in contact with Geisinger’s monetary help workplace, which provided her a self-pay low cost knocking $4,211 off the invoice. But she nonetheless owed greater than she might afford, Anderson mentioned.
The ultimate supply? She mentioned a consultant informed her by cellphone that if she made one lump fee, Geisinger would give her half off the remaining prices.
She agreed, paying $5,236 in complete.
The Takeaway
It’s at all times greatest to learn your profit booklet or name your insurer earlier than you endure a nonemergency medical process, to test whether or not there are any exclusions to protection. In addition, name and converse with a consultant. Ask what you would possibly owe out-of-pocket for the process.
While it may be exhausting to know whether or not your plan is grandfathered below the ACA, it’s price checking. Ask your insurance coverage plan, your employer, or the retiree advantages workplace that provides your protection. Ask the place the plan deviates from ACA guidelines.
With contraception, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn mentioned. “It’s incredibly hard to be an advocate for yourself.”
Most insurance policy supply on-line calculators or different methods to be taught forward of time what sufferers will owe.
Be persistent in in search of reductions. Provider prices are nearly at all times larger than what insurers would pay, as a result of they’re anticipated to barter decrease charges.
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical payments. Since 2018, this sequence has helped many sufferers and readers get their medical payments diminished, and it has been cited in statehouses, on the U.S. Capitol, and on the White House. Do you’ve a complicated or outrageous medical invoice you wish to share? Tell us about it!
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