The HOPE Act, ERISA Loopholes, and the Out-of-Network Lab Trap

Have you ever thought your top-tier insurance fully covered IVF, only to be hit with a $20,000 out-of-pocket bill? On this episode of Taco 'Bout Fertility Tuesday, Dr. Mark Amols pulls back the curtain on the confusing and frustrating world of reproductive medicine insurance.

We break down the two biggest financial illusions in fertility care:

• The ERISA Loophole: Discover the difference between fully insured and self-funded corporate plans, and learn why state IVF mandates might not legally apply to your employer.
• The Out-of-Network Lab Trap: Find out why your doctor might be in-network, but the embryology lab is not—and why the "No Surprises Act" won't protect you from these massive bills.

Finally, we discuss the newly reintroduced HOPE Act—a federal bill designed to close the corporate insurance gap—and equip you with the three essential questions you must ask your financial coordinator before starting treatment so you don't get burned.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

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Today we talk about sticker shock and the Hope Act. I'm, Dr. Mark Amels and this is Taco about Fertility Tuesday. On today's episode M, we're going to tackle one of the most frustrating and confusing parts of reproductive medicine insurance. If you're like me and you work for a good company and you had insurance and you thought your insurance was pretty good, you might be shocked to find out that many insurances do not cover reproductive medicine. And yet you see this reputable company such as Aetna, Blue Cross, UnitedHealthcare, and you feel, yeah, I should be good. You assume you have the top tier coverage because everything else is covered. But then you get to the fertility clinic, they run your benefits, and you find out that the IVF cycle is 100% out of pocket. You might even be living in a state that legally mandates IVF coverage, yet you're still being handed a bill for about$20,000. How is that legal? Well, on this podcast episode, I'm going to pull back the curtains on the biggest illusion in healthcare, the corporate insurance loophole, and talk about a new piece of legislation in Washington called the HOPE act that's trying to fix this issue. But we're not going to just pick on the big corporate companies. We're also going to talk about fertility clinics themselves and how they have found loopholes as well. You would assume if you have Aetna or Blue Cross Blue Shield or some other company, that they pay the bills when you go and have services done. And that's a reasonable belief. But what's interesting is it's not always that way. Usually it falls into one of two buckets. The first is what's called fully insured. This is what small businesses and many businesses do. They pay a monthly premium to an insurance company and that insurance company takes on the financial risk. If you need, let's say, medical care, the insurance company pays for it at their own profit. And why this is important is because state laws govern these plans. But if you work for a mid to large company, they likely use the second bucket, the self funded insurance. This is where the illusion comes in. Even though it looks like your insurance might be Aetna or Blue Cross or so forth, in reality your company is paying the bill. They are just helping the company administer the plan. Think of massive apartment complexes. The corporation you work for is the wealthy landlord who owns the entire building. And they have plenty of money in their own bank to pay for all the repairs. But the landlord doesn't want to answer the phone at 2am in the morning. So when your sink breaks and needs to be fixed, they hire a property manager to handle those calls and do the paperwork. And then they send the plumber. Well, in healthcare companies like Aetna and Blue Cross are just the property manager. Your company hires them as a third party administrator. Then Aetna, issues you an ID card and process the paperwork. But when you submit a claim for your, let's say, IVF or other treatment, Aetna, isn't paying out of their own pocket. They're just cutting the check using your employer's bank account. The employer is the one writing the rules on, what gets covered. So why does this matter? Why did I just explain all of this? Well, because of a Federal law from 1974 called ERISA, spelled E R I S A E. When an insurance plan is self funded by a corporation, it is not governed by the state, but is governed by the federal government under arisa, which completely exempts them from state laws. For example, in California, they passed a, state law mandating fertility insurance. But large companies do not have to use it because if they are self funded, the state law doesn't have control over them. And about 60% of Americans who get their health care are from self funded corporate plans. And that means state laws don't apply. So you have a large company that's self funded in California, your employer can legally look at that state mandate and say, no, thanks, we're self funded, we follow venture law and they can exclude fertility care entirely. Now, as I mentioned, I'm not going to just pick on the big companies, but also even the small fertility clinics have their own loopholes. You would assume that if you are in California and you have insurance and it's not from a self funded plan, that now your fertility is going to be covered. Well, what you're going to be surprised is, is that in, many clinics you're going to go in and you're still going to owe a lot of money out of pocket. The question is why? Well, because although your doctor is in network, your clinic's lab may not be in network. And this is a structural loophole. These clinics will structure their clinic in network, but the embryology lab outside. Now, keep in mind this isn't done just to be a loophole. There are actual legal reasons for doing this, to protect the clinic from things that can happen in the lab. But because they are separate entities, you can actually say we're in network because your clinic is. But your lab is still out of network. And so now that mandated state doesn't work so well because most of the expense is not in the clinic, it's from the lab. So sure, your Insurance covers the $200 ultrasound, but you're left holding the bag for$15,000 from Embryology and facility fees. And as a patient, it looks like one clinic. You walk down the hall from the exam room to the procedure room thinking, yeah, I haven't gone to a new clinic, but financially, you cross an invisible border into an out of network facility. And I know what you're thinking, this has to be illegal. Didn't they pass the no Surprise act to prevent things like this? They did, but unfortunately it doesn't fall into that category because it's not an emergency. And the no Surprise act was heavily geared towards emergency care or unexpected out, of network providers such as like an anesthesiologist walking in the room. The other big thing is almost all fertility centers are going to have you sign some type of financial document, which is your notice and consent. Once you sign that waiver acknowledging that the lab is out of network, you legally surrender the federal protections against surprise billing and agree to pay the higher out of pocket cost. So what was the point of this episode? Just to educate everyone? Well, yes, but also because there is things that you can do. And this brings me to the good news. The HOPE Act. HOPE stands for Helping to Optimize Patients Experiences with Fertility Service act, and it was just reintroduced to Congress. The reason the HOPE act is such a big deal is that this prevents the federal loophole that these large companies can use, which over 60% of people get their insurance from. Essentially, the Hope act says if a corporate health plan covers standard obstetrical care like having a baby, then they are legally required to also cover infertility diagnosis, treatment and standard fertility preservation. This applies to patients with diagnosed infertility, unexplained infertility, and even patients facing medical treatments like chemotherapy that threaten their future fertility. The way you can help is by calling your current representative and letting them know that you want to push this hope back through. Now, what if you fall into the other category where maybe you're in a mandated state and they aren't self funded, but yet their clinic is still out of network. Well, at this time you can't force the client to go into network, but there are questions you can ask that can help you determine if this is going on. So when you sit down with a financial person, don't just ask them, do you take my insurance? That question is a bit Of a trap. There are three questions you really need to ask. Is the embryology lab in network for my specific plan, or is it in a separate out of network entity? Two, does the doctor's in network status also apply to the facility fee for the egg retrieval and transfer? And the third question is, if the lab is out of network, do you offer a gap exception or an in for out waiver to honor my in, network benefits? If they hesitate to answer any of these, that is a big red flag. I'm, not saying they're a bad clinic and they're trying to do anything shady. I'm just saying that you need to make sure to ask more questions because you may get hit with a big bill that you weren't expecting. And as I mentioned, there is nothing illegal about it. Now, not all clinics are like this. Some of us, we're in network for everything. Now, we might be separated, different companies, but we still are in network for everything. The question is, why would someone be out of network? Well, it's not always for nefarious reasons. Sometimes some insurances won't pay very well. And so the clinic says, I can't go with that network if they're not going to pay well, so they don't go in network. The important part here is for you to know this can happen so you can ask those questions and not get burned later when you find out. Let me give you an example of how much this can affect you. Let's say the total cost is about$21,000, and the standard mandated coverage by your state says Insurance is covering 80% of the cycle. Then that means insurance will pay about$16,800 and you're just stuck with $4,200 of that bill. Now, what if the clinic was out of network when it comes to the lab? Well, then in that situation, that same $21,000 cost insurance now only pays $7,200 and you pay $13,000. Now, what about the situation where if it was self funded. Well, if it's self funded, then that state mandate doesn't matter at all. And it's still $21,000 even if they're in network because the company gets to decide what they will and won't pay for. And that's why the HOPE act is needed, because it can prevent this loophole and allow the 60 plus percent of Americans that have not just fertility coverage, but to also allow for egg freezing in situations such as needing chemotherapy. As a physician and as an owner, I see the heartbreak of this financial barrier every single day. It's one of the reasons we created our clinic. We didn't want money to be a reason someone can't have a family. Unfortunately, we can't help everyone and people do have to go to other clinics. And unfortunately, corporate insurance loopholes shouldn't allow or not allow people to be able to have a family. So if you want to help change this, look up the HOPE act, contact your federal representative and tell them to support it. And if you are in the mandated state, as we discussed, find out if you are in a company that is self funded or fully insured. Because only if they're fully insured does a state mandate pertain to you. And even if the state mandate pertains to you, then the next question is is the lab in network? And if it's not, ask those questions to help determine it so you don't get hit with a large bill. Hopefully this episode was helpful for you. Maybe you've been in this situation or you're about ready to go through IVF and thinking everything is covered. Now you know some of the things to ask to help prevent those hidden bills. If you like this podcast, please tell your friends about it. Give us a five star review on your favorite medium, but most of all, keep coming back. I look forward to talking to you again next week on Taco Belt for Fertility Tuesday.