Unmatching with our Gestational Carrier Because of Newborn Insurance
Medical insurance in the United States is complicated.
Medical insurance in the United States for American citizens living abroad is more complicated.
Medical insurance in the United States for our Swedish/American newborn child born via surrogacy is the most complicated.
This is the story of how my husband and I had to unmatch from our incredible gestational carrier (GC) after finding out the complexities of newborn insurance for international intended parents (IPs) on a surrogacy journey in the U.S.
It’s been about a week since this all transpired. We are finally ‘OK’ with it, but it’s been hard. We really connected with, trusted, and liked our GC. I was so excited that in my article describing the match, and I truly felt like she was ‘the one’ who would help us have our child (https://www.babymoonfamily.com/original-articles/we-matched-with-a-gc).
As we take one step back to rematching with another GC, there are a few important lessons that I wanted to share:
Trust but verify: When you are given advice by any professional involved in a surrogacy journey, you can believe them, but you should do your own diligence to confirm their advice.
Go with your gut: This journey requires a lot of decisions, some big and some small. Through all of them, you have to go with your gut and feel comfortable with your choices.
Insurance doesn’t lie: Insurance is a big money business that involves assessing risk. Because of this, the standards required of insurance are often a good indication of risk and should be respected.
Trust But Verify
I have written about U.S. hospital bills for international IPs (https://www.babymoonfamily.com/original-articles/us-hospital-bills). In this previous article, I discussed newborn insurance, what it covers, how much the hospital bill may be, and how to negotiate this bill down. Hospital bills are a foreign concept to most Europeans who are covered by national insurances, but the concept of negotiating to lower a hospital adds another layer of complexity to this cross-cultural medical experience.
This is why I wrote this previous article. As an American and a doctor trained in the U.S., I wanted to share this experience and knowledge with international IPs.
However, I didn’t think this advice would apply to my husband and me.
Early on in our journey we had an introductory discussion with a lawyer affiliated with our agency. It was an informational interview to see if we wanted to work with his firm. In this session, we explained our unique situation of being American citizens who live in Sweden. He quickly said that we could get coverage for our newborn through the Affordable Care Act (ACA) marketplace.
The ACA (or Obamacare, https://www.healthcare.gov/) allows Americans to purchase medical insurance if they are not covered by work, a family member, or Medicare/Medicaid. It’s been a game changer for many uninsured Americans to get health insurance and prevent bankruptcy from catastrophic medical bills.
Long story short, even though we are Americans and maintain a residence in the U.S., we do not qualify for ACA coverage. Even if we could qualify for ACA, the policies are restricted to a state or even a zip code, meaning that our California ACA coverage would not be usable for our newborn who was supposed to be born in Texas where our GC lives.
Even though this was a reputable lawyer from a well-known firm, he was not an insurance expert. He gave us inaccurate information which we believed and then assumed was correct for almost 2 years.
We trusted him completely and didn’t verify his claim at all.
Given this, we were now confronted with the reality of being in the same position as all other international IPs and needing a newborn insurance policy for our child.
Go With Your Gut
The fact that we had to now purchase newborn insurance as international IPs was not what actually led to us unmatch with our GC. The issue was actually with our GCs age, which is 42 years old.
After our online meeting with our GC, we were thrilled with everything about her personality, life, motivation to be a GC, and social support. We were thrilled with everything, except her age.
I was concerned that there would be increased risk for her and our baby because she was over 40 years of age. I reached out to our reproductive endocrinologist (REI) and asked him if this was a concern. He leveraged the American Society of Reproductive Medicine (ASRM) guidelines, which state that a GC should be between 21 and 45 years of age (1).
Obviously, age is only one aspect to a GC's overall health. A 42 year old GC could be significantly healthier than a 32 year old one who has significant medical and obstetric history. As a doctor I knew that this holistic perspective was accurate, but I still had a nagging feeling that age - while only a number - does have significant influence on the course of a pregnancy.
However, my husband and I decided to push this concern aside and continue forward. We had been waiting a long time for this match. We really liked her. Most importantly, we wanted to get pregnant and have our baby sooner rather than later.
Insurance Doesn’t Lie
This brings us back to the newborn insurance. Our agency put us in touch with a broker who gave an overview of the two newborn insurance policies they offer. Two. That’s it, and she was actually excited because it only recently increased. She said for many years, it was only one: Lloyd’s of London.
The broker that we talked with was from International Fertility Insurance (IFI), and they offer all types of insurance coverage for surrogacy journeys, including maternity, newborn, surrogate life, surrogate disability, and IVF complications (https://www.goifi.com/).
Our agency and Piece of Mind program includes all the other insurances, so we are only responsible for the newborn insurance. IFI’s publicly available information packet goes over Llyod’s of London’s policy options (2).
For the second insurance, this is actually so new that they are still negotiating and finalizing all the details of the policy, so this is not publicly available. However, during our Zoom meeting, the broker did share the policy with us, but I cannot share it here.
In both cases, there is an explicit criteria that the GC be 40 years of age or younger.
This was obviously a surprise to us given the ASRM guidelines and our agency’s reassurances, but the broker said that with a GC of 42 (or 43 by the time she delivers) could make the insurance premium more expensive, or we could be denied coverage all together.
This was a shock.
I then did some more research on pregnancy and delivery complications for women over 40, and the literature is pretty clear (3):
Among women of 40 years old and above, obstetric complications are significantly more frequent.
Pregnant women over 40 have an increased risk of the following:
Gestational diabetes
Pre-eclampsia (which can lead to eclampsia, a life-threatening complication)
Gestational hypertension
Cesarean delivery
Being over 40 also leads to significantly higher risk to the newborn, including:
Premature delivery
Fetal death in utero (FDIU)
Insurance doesn’t lie. It’s about risk and the numbers. This research supported the newborn insurance policies. GCs over 40 are too high risk to insure. Even if they can qualify through being cleared by a reputable agency or otherwise being exceptionally healthy, this policy will be more expensive.
After reading this article and realizing the risks to the GC and our unborn baby, we couldn’t continue to deny that nagging concern about age in pregnancy.
We had to break our match.
We didn’t want to be constantly worrying about our GC’s health or our baby’s health during the pregnancy and delivery. We didn’t want this unnecessary risk. We wanted what our program at Hatch is called, Piece of Mind.
Moving Forward
We learned a lot from this experience, and we still have a lot more to learn about newborn insurance.
When I have talked with Europeans about newborn insurance, many of them opt not to get it. Unlike medical coverage for the GC, newborn insurance is not mandated. You could ‘roll the dice,’ and if you have a healthy delivery and newborn with no complications, you could have a few thousand dollar bill that you negotiate down or just pay.
However, if things do not go perfectly, the bill can increase exponentially. Extra nights in a hospital or a neonatal intensive care unit (NICU) can cost thousands or tens of thousands of dollars a night.
This is not a risk we are willing to take either, and so we are most definitely going to pursue a plan. The task is now choosing which of the two plans, and within the plan, which of the options.
Here is a brief overview of the Llyod’s of London options:
They vary quite a bit in terms of coverage and deductibles, and it’s interesting that for each of them, you can spend an additional $1,000 to have ‘Billing Management’ where they negotiate the bill for you.
Since we are doing a single embryo transfer (SET) for each pregnancy attempt, and we are now optimizing for our GC’s medical profile, we should be at extremely low risk for complications.
In fact, most complications for women under 40 are due to multiples (i.e. twins or triplets). It’s because of this that virtually no clinics in the U.S. do double embryo transfers (DET). Our clinic will not permit it, and data from the U.K. shows that SET has increased from 13% of IVF cycles in 1991 to 75% in 2019 (4).
Interestingly, international IPs do not qualify for any newborn insurance policies for multiples. This is critical for us to know now, as when we get to the legal clearance with our future GC, we will have to discuss selective reduction. Less than 2% of the time, a single embryo spontaneously divides into twins (5). In this case, we will have to pursue selective reduction with our GC as we otherwise would not be able to insure the twin pregnancy from abroad.
I know I constantly refer to surrogacy for queer IPs as a journey. However, this latest stage makes it feel more like a rollercoaster. In a short span of time, we have had the high of matching with an incredible woman to be our GC to the low of unmatching through a series of learnings about the increased risk her age posed as well as the lack of newborn insurance options with a GC over 40.
However, we will continue on this wild ride, and I hope the next fun turn or climb leads us to another successful match followed by a safe and well-insured pregnancy.
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