Horizon blue cross blue shield ivf coverage

After four miscarriages and denials from Horizon Blue Cross Blue Shield of New Jersey to cover fertility treatments, Deanna and Jon Harkel braced themselves for more disappointment.

But when they read through the letter from the doctor who reviewed their appeal of the insurance denial, they were heartened. The doctor agreed with them. The service should have been covered. Horizon's decision was overturned.

"It's been so many years of such bad news continually, I was pretty shocked," Deanna Harkel said.

The Harkels are among an increasing number of New Jerseyans who are appealing their insurance denials with the state Department of Banking and Insurance. And they are finding success. More than half of the insurers' denials in recent years that have gone to appeal have been overturned.

It's a sign, state officials said, that consumers are more aware of the option and are more aggressively fighting back.

They are jumping into a fray between doctors and insurers over what constitutes medically necessary treatment. And it could intensify as new, costly breakthroughs become available.

But as the Harkels show, the process is emotionally draining, forcing them to find time to take off from work, plead their case in front of Horizon's insurance board and lose sleep.

"The consumer can sometimes be put in the middle of that and can be forced to make phone calls back and forth, which just adds stress to the consumer’s health care experience, which is really unnecessary," said Theresa Edelstein, a vice president at the New Jersey Hospital Association, a trade group.

MORE: Can Asbury tech firm help new moms steer clear of opioids?

MORE: Blame brand name drugs for rising health costs, Horizon says

Appeals program

Consumers are increasingly taking the fight to the state's Independent Health Care Appeals Program, an appeals process that has been available to many New Jersey consumers since 1997 but has rarely been used.

Horizon in a statement Thursday said it relies on medical and scientific research to "ensure that no matter how complex medical conditions or procedures may be, our coverage provides for the most appropriate and safest care, based on the best and most current clinical evidence available."

Insurers' decisions, however, are getting challenged more often.

From January to July 2018, 1,151 consumers appealed their insurance denials, up 110 percent from the same period in 2017 and more than 200 percent from the same period in 2016, according to state data.

State officials noted it is a tiny fraction of overall claims, given that more than 3 million New Jerseyans are covered by plans that are overseen by the program.

But when consumers appeal, they very often prevail. Nearly 54 percent of the appeals were overturned the first six months of 2018; 60 percent were overturned during that period in 2017; 51 percent in 2016, the data shows.

By comparison, about a third of the 136 appeals during the first six months of 2008 were overturned, according to the state.

"The reason for the recent surge is likely due to provider and consumer awareness of the right to appeal," a Banking and Insurance Department spokesman said.

Settling down, the time was right

The Harkels were grateful for the state's appeals process.

But they said they could have been spared some pain if their request for coverage had been approved right off the bat.

As it was, they endured a fourth miscarriage, sleepless nights, countless blood tests and a drive to Horizon's headquarters in Newark to make what was ultimately an unsuccessful plea in front of the insurer's appeals board.

The Harkels, both 31, live in Hightstown. Deanna is director of donor relations for a private school. Jon works in the communications office at a New York college. 

They met when they were students at the College of New Jersey in Ewing and got married five years ago. They began their careers, bought a house and decided two years ago that the time was right to start a family, even as they took on extra work to make ends meet.

MORE: Paid sick leave underway in New Jersey

MORE: Designer baby? NJ lab closer to making science fiction reality

The Harkels had little trouble getting pregnant, but during a doctor's visit, the nurse became strangely quiet.

"We went for the first ultrasound, we were expecting the whole (to do), you print out the picture and all that stuff," Jon Harkel said. "The nurse had her poker face and Deanna said, 'Do you see anything?' And she said, 'We’ll have to wait for the doctor,' and we were, like, all right this is a problem.”

The pregnancy wasn't viable. Deanna miscarried. They got pregnant again. And Deanna miscarried again, prompting them to test the fetus for chromosomal abnormalities, the most common explanation for miscarriages.

The results showed abnormalities, and the Harkels were referred to Dr. Debbra Keegan, a reproductive endocrinologist with the Institute for Reproductive Medicine and Science at Saint Barnabas.

Keegan suggested they try again, noting they were statistically unlikely to have a third miscarriage. They tried again. They miscarried again.

That's when Keegan recommended in-vitro fertilization along with a preimplantation genetic test that can detect genetic defects in an embryo before it is transferred to the uterus. 

The test, she said, would allow her to choose a healthier embryo and enhance their chances for a viable pregnancy. But they ran into a roadblock. Horizon wouldn't approve it. 

Appeals rise across the board

It isn't clear how often such insurance claims are denied. But the spike in appeals comes as a surprise. 

Insurers have been touting closer cooperation with health providers in recent years to try to deliver more cost-effective care.

But the data shows battles between insurers and providers are continuing. The bulk of the appeals stems from disagreements over prescription drugs and hospital inpatient admissions.

MORE: NJ upends how doctors get paid, but C-section rates remain high

MORE: NJ Obamacare premiums fall 9.2 percent for '19

But most specialties saw an increase. Internal medicine jumped from 48 cases the first six months of 2017 to 298 cases for the same time in 2018. Infectious disease rose from 41 cases to 104 cases. Gastroenterology rose from 132 cases to 165 cases.

OB/GYN, neonatology remained level at 23.

What gives? Theories abound:

• More New Jerseyans have insurance through the Affordable Care Act, commonly known as Obamacare.
• Insurers, faced with rising prescription drug prices, are getting pushback when they steer consumers to less expensive generic drugs.
• The state Department of Banking and Insurance increased public awareness last March by reminding consumers and providers about their rights to appeal denials.
• Doctors and hospitals are becoming more likely to fight initial denials, knowing that if they prevail, it could be a deterrent to insurers in the future. 

"It’s a huge drain of resources on the system," Larry Downs, chief executive officer of the Medical Society of New Jersey, a trade group representing physicians, said of the need to get insurer's approvals before delivering care. "It’s a cost issue and it’s a patient care issue."

The fine print

The Harkels soon were caught in a medical dispute.

In-vitro fertilization costs about $15,000; genetic testing costs thousands more. And there was a chance the procedure wouldn't be successful and they would have to try again.

They weren't worried. They were covered by Horizon through Deanna's job. They contribute $5,203 a year toward their premium. The policy includes co-pays of $50 for specialists, but no deductible for in-network providers.  

What's more, New Jersey mandates insurers cover fertility treatment for women who cannot get pregnant or carry a pregnancy to live birth.

But the Harkels found the law and their policy wasn't cut and dried. 

Before covering IVF, Horizon required the Harkels to try less expensive measures, including intrauterine insemination, placing sperm inside the uterus.

For the fourth time, Deanna got pregnant. For the fourth time, she miscarried. When they asked Horizon to authorize IVF and the genetic test, they were denied again, prompting them to appeal the decision.

MORE: Hackensack Meridian gives nurses raises, pledges to hire more

MORE: NJ pounds UnitedHealthcare with $2.5M fine

The Harkels and Keegan drove to Horizon's headquarters in Newark just before Thanksgiving. They took their seats in a conference room and, in front of a committee of what they said was about 10, they made their plea.

The gist of it? They had been on a physical and emotional roller coaster and were simply trying to collect on insurance for a medically necessary procedure.

A Horizon employee called the next day, the Harkels said, and told them that the committee stood by the company's initial decision.

"I’ve been sad for two years," Deanna Harkel said after the denial. "And now I’m just angry. I’m angry that they’re asking me to continue to have miscarriages when they have the science and technology to (use) IVF. The science is there. The technology is there. The answer is there, and we pay for it in our policy."

The value of genetic testing

Horizon disagreed. Its committee said preimplantation genetic testing for the Harkels was considered investigational, making it a service that went beyond the state's fertility mandate.

While Keegan pointed to studies that showed the test reduces the miscarriage rate for IVF patients, Horizon referred to a 2018 study by the American Society of Reproductive Medicine that concluded the value of genetic testing on embroys on all IVF patients had yet to be determined.

Horizon in a statement said it relies on recommendations of medical and scientific organizations.

"In Ms. Harkel’s case, the current standards established by the research and recommended by those expert organizations did not support the treatment Ms. Harkel sought, a decision that was affirmed by an independent, board-certified specialist during the (internal company) appeal process," it said.

The Harkels appealed their case again, this time with the state. And they anxiously awaited the decision, knowing if they lost, they would have to wait a year to ask their insurer to authorize IVF and genetic testing.

The decision arrived just before Christmas. The outside doctor who reviewed the case said preimplantation genetic testing was considered medically necessary given the couple's history of miscarriage. He recommended the denial of coverage be overturned.

"While we stand by our policies and the science on which they are based, this issue is settled and our focus is on continuing to support the Harkels as they work to grow their family,” Horizon said in a statement.

The Harkels were free to proceed. They plan to start IVF any day now.

"We're on the path we should have been a long time ago," Jon Harkel said after the decision. "It's hard to be too excited. There was a moment where I was really grateful they did the right thing, but I felt weird being appreciative that somebody did what they were supposed to do."

"I think we’d like to start the process," Deanna Harkel said. "It’s a long process. This is just beginning. We’d like to start as soon as possible. Hopefully we’ll get some good news in 2019."

Does horizon insurance cover IVF in NJ?

How much does IVF cost in NJ?

Does Blue Cross Texas cover IVF?

What insurance covers IVF in VA?