Health Insurance Child Birth When to Change to Family Plan

Mikkel and Kayla Kjelshus' daughter, Charlie, had a complication during delivery that caused her oxygen levels to drop and put her at hazard for brain damage. Charlie needed seven days of neonatal intensive care, which resulted in a huge bill — $207,455 for the NICU alone — and defoliation over which parent's insurer would cover the little girl's wellness costs. Christopher Smith for KHN hide caption

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Christopher Smith for KHN

Mikkel and Kayla Kjelshus' girl, Charlie, had a complication during delivery that caused her oxygen levels to driblet and put her at risk for brain damage. Charlie needed seven days of neonatal intensive care, which resulted in a huge pecker — $207,455 for the NICU alone — and defoliation over which parent'due south insurer would comprehend the little girl'due south wellness costs.

Christopher Smith for KHN

In the nine months leading upwardly to her due date, Kayla Kjelshus and her married man, Mikkel, meticulously planned for their daughter's arrival.

Their long to-do listing included mapping out their family'south wellness insurance plan and registering for baby gear and supplies. They even nailed down kid care ahead of her birth.

"We put a deposit downwardly to hold a spot at a local day care following our beginning ultrasound," says Kayla Kjelshus, of Olathe, Kan.

The first-fourth dimension parents felt ready for their daughter'due south debut on Feb. 15, 2019. Simply ane of the happiest days of their lives turned out to exist one of the scariest. Their daughter, Charlie, had a complexity during delivery that caused her oxygen levels to drop and put her at gamble for encephalon damage.

"We had a waiting room filled with family and friends," Mikkel recalls. "To come out and say things aren't well ... it was really hard."

Charlie was transferred from Saint Luke'south Community Hospital to HCA Overland Park Regional Medical Center, where she received treatment in the neonatal intensive intendance unit, known as the NICU, for the next seven days.

Doctors sent Charlie home with a positive prognosis. The couple had decided that Kayla, a nurse practitioner, would carry Charlie on her insurance plan through Blue Cross and Blueish Shield of Kansas Metropolis. Her plan offered improve rates than Mikkel's, and his plan was based in another country and carried a higher deductible. So when the hospital asked for insurance information, Kayla provided her policy number — Mikkel did not.

They expected things to work out fine betwixt the insurance company and the hospitals.

And so the bills came.

The Patient: Charlie Kjelshus, an infant covered past her mother's plan through Blue Cross and Blue Shield of Kansas City and, eventually, her begetter's plan, CommunityCare of Oklahoma

Medical Service: Whole torso cooling and other treatment in the NICU to preclude brain injury that may result from oxygen impecuniousness during nativity

Service Provider: HCA Overland Park Regional Medical Middle in Overland Park, Kan.

Full Bill: Multiple charges totaling $270,951, according to Mikkel Kjelshus, including a charge of $207,455 for the NICU stay

What Gives: Kayla Kjelshus filed a claim with Blue KC, and the insurer started paying for baby Charlie's care. But then information technology canceled payments to the HCA Overland Park hospital, St. Luke'south Customs Hospital and Charlie's neurologist, pediatrician and other physicians.

"We thought, 'This is crazy,'" Mikkel says. "'Nosotros have insurance.'"

What was going on?

The Kjelshus family unit had slammed into something well known among insurance experts simply little understood by the full general public. "Coordination of benefits" and "the birthday rule" are the jargon terms for the red tape that snared them.

When a kid is born into a family unit in which both parents have insurance through their jobs, the parents are supposed to "coordinate benefits'' — meaning they must tell both insurers that their kid is eligible for coverage under two plans. The parents might be forgiven for thinking they have some say in how their child will be insured. In most cases, they don't.

Instead, a child with double health insurance eligibility must take equally principal coverage the plan of the parent whose birthday comes first in the agenda year; the other parent'due south insurance is considered secondary. This model regulation was prepare by the National Clan of Insurance Commissioners and adopted by nearly states, including Kansas, says Lee Modesitt, director of government affairs with the Kansas Insurance Section.

For Charlie Kjelshus, the birthday dominion meant her dad's plan — with a $12,000 deductible, loftier coinsurance obligation and a network focused in a different state — was master. Her mom'due south more generous plan was secondary.

Mom Kayla says Blue KC dispatched an investigator to discover that dad Mikkel had insurance through his job. The family had not been trying to hide Mikkel's coverage; they just weren't enlightened of the birthday rule and that they may be subject to state laws that ensure babies are covered for the first 31 days of life.

"If these are the rules of engagement, yous need to tell people upfront that these are the rules," says Dr. Linda Burke, OB-GYN and author of The Smart Mother's Guide to a Ameliorate Pregnancy. "It's a communication problem."

After Bluish KC informed Mikkel that his insurance had to serve equally primary coverage, CommunityCare of Oklahoma did pay Charlie'south bills to the hospitals and other providers. It paid HCA Overland Park $16,605 on the $207,455 NICU charge. The insurer said its negotiated charge per unit on the beak was $35,721. With Mikkel's deductible and coinsurance, that left the family unit on the hook for more than $xix,116, information technology seemed.

"When an insurance company finds out that a infant is in the NICU, then information technology'due south a red flag," Burke says. "They are going to look for ways to cut their losses."

Resolution: The couple turned to the Kansas Department of Insurance to file a complaint about the bill, but the department declined to help because Kayla's policy is self-funded by her employer, which means the visitor is subject to federal rather than state regulations.

Afterwards close to a year and a half of going back and along with their insurance companies and the hospitals, Bluish KC paid $19,116 of the Kjelshuses' bill equally a secondary insurer and said the Kjelshuses should not be responsible for what HCA Overland Park said was a remaining balance of $vii,504.51. But the family kept getting bills.

And, commencement in summer 2020, collections calls from the infirmary rolled in daily, leaving the couple frustrated and confused.

Eventually, after a human resources officeholder at Kayla's job stepped in to aid, they received a argument with a zero remainder. Their own calls to HCA Overland Park hospital billing department didn't get them anywhere.

"We ever got a dissimilar answer," Kayla says. "It was so frustrating."

A spokesperson for the hospital apologized for the deluge of calls from collections.

"We made an authoritative error and an automatic billing call system for payment occurred, causing the family undue frustration during an already stressful time, and we apologize," the hospital wrote in a statement. "In one case the issue was identified and resolved, the insurance companies processed the claim and we informed the family unit that there is a zero balance on the business relationship. Again, we are sorry for the stress and inconvenience, and wish them well."

In a statement, Blue KC best-selling that coordination of benefits can be confusing for members and that the company follows rules of state and federal regulators, modeled on standards set up by the NAIC. It said that the Kjelshuses' futurity claims would proceed to be paid and that a "dedicated service consultant" would proceed to work with Kayla Kjelshus.

In the stop, the insurers and hospitals settled Charlie's bill as they were supposed to: The primary insurer paid first, and the secondary paid what had not been covered past the offset. Only it took more than a year of telephone calls, appeals and complaints before the Kjelshus family had the matter settled. Charlie turns 2 adjacent month.

For Charlie Kjelshus, "the altogether rule" meant that dad Mikkel's programme ― with a $12,000 deductible, high coinsurance obligation and a network focused in some other land ― was deemed her primary coverage after her NICU stay equally a newborn. Mom Kayla's more generous programme was considered secondary coverage. Christopher Smith for KHN hibernate explanation

toggle caption

Christopher Smith for KHN

For Charlie Kjelshus, "the altogether rule" meant that dad Mikkel'due south plan ― with a $12,000 deductible, high coinsurance obligation and a network focused in another country ― was deemed her chief coverage afterwards her NICU stay as a newborn. Mom Kayla's more generous plan was considered secondary coverage.

Christopher Smith for KHN

The Takeaway: In theory, "the birthday dominion" would exist a off-white, if random, fashion to effigy out which insurance should be primary and which secondary for families with insurance from two employers. The presumption is that the premiums, deductibles and networks are roughly similar in both parents' insurance plans — just that'due south only not the case for many families.

The Kjelshuses found out the hard way they didn't have a choice about which parent'southward insurance was main. They might accept avoided their quagmire if Mikkel had dropped his own coverage and gotten onto Kayla's plan earlier Charlie was born.

It's non clear whose responsibility it is to assist families navigate these rules earlier a baby is born. It's even more complicated for parents who are divorced or never married. Insurance companies don't always offer the critical data families need about the coordination of benefits.

"Expecting parents should try to go in bear on with their health plan earlier the infant is born to find out about the coverage rules," says Karen Pollitz, a senior young man at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of KFF.)

New parents should "also effigy out if they want to switch the entire family unit onto one programme once the baby is born."

It's also a good idea to speak to human resources representatives at both parents' jobs. The birth of a infant is considered "a qualifying event" for insurance coverage in all group health plans, and then families tin can make decisions about changing coverage at that time. Otherwise, families might have to look for open enrollment to brand coverage changes.

"It is ridiculous to me my wife and I faced then many problems since both parents accept wellness insurance," Mikkel Kjelshus says. His daughter, Charlie, now is covered only by his wife'southward plan.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with the states? Tell us near information technology!

Stephanie O'Neill reported the radio version of this story. Ari Shapiro's chat with KHN Editor-in-Primary Elisabeth Rosenthal aired on All Things Considered.

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Source: https://www.npr.org/sections/health-shots/2021/01/27/961196647/birthday-rule-blindsides-first-time-parents-with-a-mammoth-medical-bill

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