By Julie Appleby

During her annual OB-GYN visit, Callie Anderson asked about getting off the birth control pill. “We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered 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 said. She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well. “I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus. Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

Mike McMullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance 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 variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she added.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income. Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. 

(KFF/JP)