Are New Born Babies Covered by Moms Health Insurance
Mikkel and Kayla Kjelshus' daughter, Charlie, had a complication during delivery that acquired her oxygen levels to drib and put her at risk for brain damage. Charlie needed seven days of neonatal intensive care, which resulted in a huge neb — $207,455 for the NICU lonely — and defoliation over which parent's insurer would comprehend the little daughter'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 drop and put her at adventure for brain harm. Charlie needed 7 days of neonatal intensive care, which resulted in a huge nib — $207,455 for the NICU alone — and confusion over which parent's insurer would embrace the little girl'due south health costs.
Christopher Smith for KHN
In the 9 months leading upwardly to her due date, Kayla Kjelshus and her husband, Mikkel, meticulously planned for their daughter's arrival.
Their long to-do listing included mapping out their family's health insurance plan and registering for baby gear and supplies. They even nailed down child intendance ahead of her birth.
"We put a deposit downward to hold a spot at a local solar day intendance post-obit our starting time ultrasound," says Kayla Kjelshus, of Olathe, Kan.
The kickoff-time parents felt ready for their girl'southward debut on February. 15, 2019. But one of the happiest days of their lives turned out to be one of the scariest. Their daughter, Charlie, had a complication during commitment that caused her oxygen levels to driblet and put her at risk for encephalon damage.
"Nosotros had a waiting room filled with family and friends," Mikkel recalls. "To come up out and say things aren't well ... it was really hard."
Charlie was transferred from Saint Luke's Customs Hospital to HCA Overland Park Regional Medical Center, where she received treatment in the neonatal intensive care unit, known as the NICU, for the adjacent 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 program through Blue Cross and Bluish Shield of Kansas Urban center. Her plan offered better rates than Mikkel's, and his plan was based in another state 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 between the insurance company and the hospitals.
Then the bills came.
The Patient: Charlie Kjelshus, an infant covered by her mother's program through Blue Cross and Blueish Shield of Kansas City and, eventually, her father'south plan, CommunityCare of Oklahoma
Medical Service: Whole body cooling and other treatment in the NICU to prevent brain injury that may issue from oxygen deprivation during birth
Service Provider: HCA Overland Park Regional Medical Center in Overland Park, Kan.
Total Bill: Multiple charges totaling $270,951, co-ordinate to Mikkel Kjelshus, including a charge of $207,455 for the NICU stay
What Gives: Kayla Kjelshus filed a claim with Blueish KC, and the insurer started paying for infant Charlie's care. But so it canceled payments to the HCA Overland Park hospital, St. Luke'south Community Hospital and Charlie'southward neurologist, pediatrician and other physicians.
"Nosotros idea, 'This is crazy,'" Mikkel says. "'We have insurance.'"
What was going on?
The Kjelshus family had slammed into something well known amongst insurance experts simply little understood by the full general public. "Coordination of benefits" and "the birthday rule" are the jargon terms for the scarlet tape that snared them.
When a kid is built-in into a family unit in which both parents accept insurance through their jobs, the parents are supposed to "coordinate benefits'' — significant they must tell both insurers that their child is eligible for coverage under two plans. The parents might be forgiven for thinking they take some say in how their child will be insured. In nigh cases, they don't.
Instead, a kid with double health insurance eligibility must accept equally main coverage the plan of the parent whose birthday comes first in the calendar year; the other parent'south insurance is considered secondary. This model regulation was set past the National Association of Insurance Commissioners and adopted by almost states, including Kansas, says Lee Modesitt, director of government affairs with the Kansas Insurance Department.
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 unlike land — was primary. Her mom'due south more generous plan was secondary.
Mom Kayla says Bluish KC dispatched an investigator to notice that dad Mikkel had insurance through his job. The family had non been trying to hide Mikkel'due south coverage; they just weren't aware of the altogether rule and that they may be subject to state laws that ensure babies are covered for the starting time 31 days of life.
"If these are the rules of engagement, you demand to tell people upfront that these are the rules," says Dr. Linda Burke, OB-GYN and writer of The Smart Female parent'due south Guide to a Better Pregnancy. "It's a communication trouble."
After Blue KC informed Mikkel that his insurance had to serve every bit master coverage, CommunityCare of Oklahoma did pay Charlie'southward bills to the hospitals and other providers. It paid HCA Overland Park $xvi,605 on the $207,455 NICU charge. The insurer said its negotiated rate on the bill was $35,721. With Mikkel'south deductible and coinsurance, that left the family on the hook for more than $19,116, it seemed.
"When an insurance company finds out that a babe is in the NICU, then it'south a red flag," Burke says. "They are going to wait for ways to cut their losses."
Resolution: The couple turned to the Kansas Department of Insurance to file a complaint about the beak, but the department declined to assistance because Kayla'due south policy is self-funded past her employer, which means the company is subject to federal rather than state regulations.
Afterwards shut to a year and a half of going back and forth with their insurance companies and the hospitals, Blue KC paid $19,116 of the Kjelshuses' nib as a secondary insurer and said the Kjelshuses should not exist responsible for what HCA Overland Park said was a remaining residuum of $7,504.51. But the family kept getting bills.
And, get-go in summertime 2020, collections calls from the infirmary rolled in daily, leaving the couple frustrated and dislocated.
Eventually, later a human resource officer at Kayla's job stepped in to help, they received a statement with a naught residue. Their own calls to HCA Overland Park hospital billing department didn't get them anywhere.
"We always got a unlike respond," Kayla says. "It was so frustrating."
A spokesperson for the infirmary apologized for the deluge of calls from collections.
"We made an authoritative error and an automated billing call organisation for payment occurred, causing the family undue frustration during an already stressful time, and we repent," the infirmary wrote in a statement. "Once the outcome was identified and resolved, the insurance companies processed the claim and we informed the family that there is a zero balance on the business relationship. Again, nosotros are sorry for the stress and inconvenience, and wish them well."
In a statement, Blue KC acknowledged that coordination of benefits tin be disruptive for members and that the company follows rules of land and federal regulators, modeled on standards set past the NAIC. It said that the Kjelshuses' future claims would continue to be paid and that a "dedicated service consultant" would continue to work with Kayla Kjelshus.
In the end, the insurers and hospitals settled Charlie'south bill as they were supposed to: The main insurer paid outset, and the secondary paid what had not been covered past the kickoff. But it took more than than a year of telephone calls, appeals and complaints before the Kjelshus family had the matter settled. Charlie turns 2 next calendar month.
For Charlie Kjelshus, "the birthday rule" meant that dad Mikkel's plan ― with a $12,000 deductible, high coinsurance obligation and a network focused in another state ― was deemed her primary coverage afterwards her NICU stay as a newborn. Mom Kayla's more than generous plan was considered secondary coverage. Christopher Smith for KHN hide caption
toggle caption
Christopher Smith for KHN
For Charlie Kjelshus, "the altogether rule" meant that dad Mikkel'south plan ― with a $12,000 deductible, high coinsurance obligation and a network focused in another country ― was deemed her master coverage after her NICU stay every bit a newborn. Mom Kayla's more generous plan was considered secondary coverage.
Christopher Smith for KHN
The Takeaway: In theory, "the birthday rule" would be a fair, if random, way to figure out which insurance should exist 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 — only 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's insurance was primary. They might have avoided their quagmire if Mikkel had dropped his own coverage and gotten onto Kayla'southward plan before Charlie was born.
It'southward non clear whose responsibility it is to assist families navigate these rules before a baby is born. It'due south even more than complicated for parents who are divorced or never married. Insurance companies don't always offer the critical information families need about the coordination of benefits.
"Expecting parents should try to get in bear on with their health program before the baby is born to find out about the coverage rules," says Karen Pollitz, a senior boyfriend at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of KFF.)
New parents should "also figure out if they desire to switch the entire family onto one programme once the baby is built-in."
It'south too a good idea to speak to human resource representatives at both parents' jobs. The birth of a baby is considered "a qualifying event" for insurance coverage in all grouping health plans, then families tin can make decisions near changing coverage at that time. Otherwise, families might have to expect for open up enrollment to make coverage changes.
"It is ridiculous to me my married woman and I faced so many issues since both parents have health insurance," Mikkel Kjelshus says. His daughter, Charlie, now is covered merely by his wife's programme.
Bill of the Month is a crowdsourced investigation past KHN and NPR that dissects and explains medical bills. Do y'all have an interesting medical bill you desire to share with us? Tell united states virtually it!
Stephanie O'Neill reported the radio version of this story. Ari Shapiro'south chat with KHN Editor-in-Main Elisabeth Rosenthal aired on All Things Considered.
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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