Madison couple faces added hurdle in infertility family planning: Insurance coverage

MADISON, Wis. (WMTV) - Matt and David Clark-Sally were expecting the complicated medical treatments, lab procedures and search for a surrogate. But they say they weren’t expecting a battle with their insurance company. The couple says insurance is outdated and not keeping up with science. They say that needs to change.

“We’re so excited and we can’t wait to grow our family and extend our love,” exclaims David Clark-Sally.

Married for two years, together for four, after one year of preparation, Matt and David are expecting a baby.

“A little bit of science, a lot of love,” says Matt.

That’s how Matt explains his next baby’s birth to his two children from a previous marriage. It’s an overly simplified explanation about a process that’s been anything but.

“As two men we obviously don’t have all the necessary pieces of the puzzle to have a baby on our own. When we decided we did want to do this, to add to our family, you really have two main options. You have adoption, and you have surrogacy IVF,” says David.

The couple chose the latter, in vitro fertilization using an anonymous egg donor and a gestational carrier.

“A lot of insurance companies, most don’t cover much when it comes to infertility as a whole. When they do cover it, you have to prove your infertility,” says Matt.

Insurance mandates all over the country define infertility as the absence of conception after at least one year of regular, unprotected intercourse.

“Well, how do two gay men prove that? So that’s a known hurdle for gay men having a baby,” explains Matt.

Matt and David have a family HMO insurance plan from Group Health Cooperative of South Central Wisconsin, or GHC. Under their plan, they knew they would have to pay out of pocket for their infertility treatment, costs for many families averaging $30,000 for IVF and $8,000 for an egg donor. Those costs are according to Forward Fertility in Madison, Wisconsin.

Matt and David got a healthy embryo on their first try, so it was time to find someone to carry it.

“Overall, there are way more families in need than women willing and qualified to do so,” says Christie Olsen, founder of Forward Fertility, and women’s health nurse practitioner.

Olsen’s clinic connects families with gestational carriers. Since opening her own practice back in 2013, she says she’s helped bring 85 to 90 babies into the world.

Olsen says to become a gestational carrier, a woman has to be 21 to 40 years old, she has to have had at least one healthy, full-term pregnancy, be a normal weight and height, be a non-smoker, be on minimal medications, and she can’t be on public assistance programs. Her values also have to match with the family she’s carrying for.

“It requires such a huge amount of trust for them to experience this process, to put their trust in someone else with the most important thing you could possibly think of,” explains Olsen.

All those things combined, Olsen says only about 3% of people who start looking into surrogacy actually become a gestational carrier.

“It’s like looking for a needle in a haystack,” says Matt.

After a 10-month search, Matt and David say the closest match they could find was a carrier in Saint Louis. A match that carries with it an additional cost of $50,000. Add in $13,000 for legal fees and $10,000 for carrier medications, the total before the baby is even born is roughly $111,000, according to Forward Fertility.

“The understanding with our insurance company and with a lot, is that this whole process isn’t covered, but once there’s a baby in this world, it kicks in,” explains David.

Matt and David say they were under the impression their insurance would pay for their baby’s hospital care once they’re born.

“Unfortunately recently, we were informed by our insurance company that they would not be covering the delivery and birth of our baby girl and her time in the hospital,” says David.

The couple appealed the decision three times, but were denied, a decision that adds at least $3,000 to $5,000 to the out of pocket baby bill.

NBC15 Investigates reached out to GHC asking to sit down with their CEO in-person to find out why the baby won’t be covered. After four phone calls and five emails, the company’s media communications manager said the CEO would not be sitting down for an interview. But they sent a written response via email saying since the baby will be born out of network, they won’t be covered under their plan:

“GHC-SCW covers in-network, planned care, including childbirth and newborn care, under the terms of any member’s HMO plan either in the individual market, or as provided by their employer. Employer groups also have the option of making PPO (Preferred Provider Organization) plans or POS (Point of Service) plans available to their staff as an alternative, either through GHC or another carrier, to provide out-of-network care for employees and their families. GHC-SCW applies policies consistently and does not discriminate on the basis of sex, gender identity, sexual orientation, marital status, or any other characteristic of the parent(s), intended parent(s), or newborn.”

“The hard part and frustrating part behind it is the insinuation behind the decision that this is easy. We should of chosen someone locally in our backyard and then we wouldn’t be in this situation. But we established, its not that easy,” explains David.

“Insurance is way behind the science. We’re in a day in age where assisted reproductive technology is a beautiful part of science. It can help people find their family just as adoption is. To have policies written that are so exclusive to family planning in that way is just baffling,” says Matt.

No matter how difficult, there’s no challenge these parents won’t tackle for their future child. They’re sharing their journey to help make change for families of all make ups for years to come.

Seventeen states in the U.S. have laws that require insurance companies to cover a portion of the costs of infertility treatments. Wisconsin is not one of those states. NBC15 Investigates went to the Wisconsin State Capitol to talk to lawmakers to see if any sort of bill is in the works. We sat down with Democratic State Representative Lisa Subeck who represents the 78th district including Madison. She says there is a bill in the works.

“There is a group of us here in the legislature who have been talking about this issue who have been working with advocates and medical experts to determine how to best address it, and I do expect us to come forward with legislation again to insure people have access to infertility treatments,” says Representative Subeck.

Back in 2015, Representative Subeck sponsored a bill that would have required insurance coverage for infertility treatment in Wisconsin. No Republicans signed on in support, so it did not pass.

Subeck says a bill of that nature is still important today.

“Any time we think about legislation like this, we need to be as inclusive as we possibly can and recognize that some people are seeking infertility treatment because they are suffering from infertility. Others are seeking fertility treatment because it’s the only way they can grow their family. Whatever the circumstance is, the goal is to ensure all families have access to the tools they need to grow as they choose,” says Subeck.

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