Child Blues: First-Time Dad and mom Blindsided by ‘the Birthday Rule’ and a $207,455 NICU Invoice

Within the 9 months main as much as her due date, Kayla Kjelshus and her husband, Mikkel, meticulously deliberate for his or her daughter’s arrival.

Their lengthy to-do record included mapping out their household’s medical insurance plan and registering for child gear and provides. They even nailed down baby care forward of her start.

“We put a deposit down to carry a spot at an area day care following our first ultrasound,” mentioned Kayla Kjelshus, of Olathe, Kansas.

The primary-time dad and mom felt prepared for his or her daughter’s debut on Feb. 15, 2019. However one of many happiest days of their lives turned out to be one of many scariest. Their daughter, Charlie, had a complication throughout supply that brought about her oxygen ranges to drop and put her in danger for mind harm.

“We had a ready room crammed with household and associates,” Mikkel recalled. “To return out and say issues aren’t effectively … it was actually laborious.”

Charlie was transferred from St. Luke’s Group Hospital to HCA Overland Park Regional Medical Middle, the place she acquired remedy within the neonatal intensive care unit, generally known as the NICU, for the following seven days.

Docs despatched Charlie house with a constructive prognosis. The couple had determined that Kayla, a nurse practitioner, would carry Charlie on her insurance coverage plan by means of Blue Cross and Blue Protect of Kansas Metropolis. Her plan provided higher charges than Mikkel’s, and his plan was based mostly in one other state and carried a better deductible. So when the hospital requested for insurance coverage data, Kayla offered her coverage quantity; Mikkel didn’t.

They anticipated issues to work out high-quality between the insurance coverage firm and the hospitals.

Then the payments got here.

The Affected person: Charlie Kjelshus, an toddler coated by her mom’s plan by means of Blue Cross and Blue Protect of Kansas Metropolis and, finally, her father’s plan, CommunityCare of Oklahoma

Medical Service: Complete physique cooling and different remedy within the NICU to forestall mind damage which will end result from oxygen deprivation throughout start

Service Supplier: HCA Overland Park Regional Medical Middle in Overland Park, Kansas

Complete Invoice: A number of prices totaling $270,951, in response to Mikkel Kjelshus, together with a cost of $207,455 for the NICU keep

What Offers: Kayla Kjelshus filed a declare with Blue KC, and the insurer began paying for child Charlie’s care. However then it canceled funds to the HCA Overland Park hospital, St. Luke’s Group Hospital and Charlie’s neurologist, pediatrician and different physicians.

“We thought, ‘That is loopy,’” Mikkel mentioned. “‘We now have insurance coverage.’”

What was occurring?

The Kjelshus household had slammed into one thing well-known amongst insurance coverage specialists however little understood by most people. “Coordination of advantages” and “the birthday rule” are the jargon phrases for the purple tape that snared them.

When a toddler is born right into a household through which each dad and mom have insurance coverage by means of their jobs, the dad and mom are alleged to “coordinate advantages” — that means they need to inform each insurers that their baby is eligible for protection beneath two plans. The dad and mom is likely to be forgiven for pondering they’ve some say in how their baby can be insured. Normally, they don’t.

As an alternative, a toddler with double medical insurance eligibility should take as main protection the plan of the father or mother whose birthday comes first within the calendar yr; the opposite father or mother’s insurance coverage is taken into account secondary. This mannequin regulation was set by the Nationwide Affiliation of Insurance coverage Commissioners and adopted by most states, together with Kansas, mentioned Lee Modesitt, director of presidency affairs with the Kansas Insurance coverage Division.

For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a excessive coinsurance obligation and a community targeted in a distinct state — was main. Her mother’s extra beneficiant plan was secondary.

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Mother Kayla mentioned Blue KC dispatched an investigator to find that dad Mikkel had insurance coverage by means of his job. The household had not been making an attempt to cover Mikkel’s protection; they merely weren’t conscious of the birthday rule and that they could be topic to state legal guidelines that guarantee infants are coated for the primary 31 days of life.

“If these are the principles of engagement, it’s worthwhile to inform individuals upfront that these are the principles,” mentioned Dr. Linda Burke, an OB-GYN and creator of “The Sensible Mom’s Information to a Higher Being pregnant.” “It’s a communication downside.”

After Blue KC knowledgeable Mikkel that his insurance coverage needed to function main protection, CommunityCare of Oklahoma did pay Charlie’s payments from the hospitals and different suppliers. It paid HCA Overland Park $16,605 on the $207,455 NICU cost. The insurer mentioned its negotiated fee on the invoice was $35,721. With Mikkel’s deductible and coinsurance, that left the household on the hook for greater than $19,116, it appeared.

“When an insurance coverage firm finds out {that a} child is within the NICU, then it’s a purple flag,” Burke mentioned. “They’ll search for methods to chop their losses.”

Decision: The couple turned to the Kansas Division of Insurance coverage to file a criticism concerning the invoice, however the division declined to assist as a result of Kayla’s coverage is self-funded by her employer, which suggests the corporate is topic to federal reasonably than state laws.

After near a yr and a half of going backwards and forwards with their insurance coverage firms and the hospitals, Blue KC paid $19,116 of the Kjelshuses’ invoice as a secondary insurer and mentioned the Kjelshuses shouldn’t be liable for a remaining steadiness of $7,504.51 from HCA Overland Park. However the household saved getting payments.

And, starting in summer time 2020, collections calls from the hospital rolled in each day, leaving the couple pissed off and confused.

Finally, after a human assets officer at Kayla’s job stepped in to assist, they acquired a press release with a zero steadiness. Their very own calls to HCA Overland Park hospital billing division didn’t get them wherever.

“We at all times bought a distinct reply,” Kayla mentioned. “It was so irritating.”

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

“We made an administrative error and an automatic billing name system for cost occurred, inflicting the household undue frustration throughout an already nerve-racking time, and we apologize,” the hospital wrote in a press release. “As soon as the problem was recognized and resolved, the insurance coverage firms processed the declare and we knowledgeable the household that there’s a zero steadiness on the account. Once more, we’re sorry for the stress and inconvenience, and want them effectively.”

In a press release, Blue KC acknowledged that coordination of advantages might be complicated for members, and that the corporate follows guidelines of state and federal regulators, modeled on requirements set by the NAIC. It mentioned the Kjelshuses’ future claims would proceed to be paid and {that a} “devoted service advisor” would proceed to work with Kayla Kjelshus.

Ultimately, the insurers and hospitals settled Charlie’s invoice as they have been alleged to: The first insurer paid first, and the secondary paid what had not been coated by the primary. Nevertheless it took greater than a yr of telephone calls, appeals and complaints earlier than the Kjelshus household had the matter settled. Charlie turns 2 subsequent month.

The Takeaway: In principle, “the birthday rule” can be a good, if random, method to determine which insurance coverage must be main and which secondary for households with insurance coverage from two employers. The presumption is that the premiums, deductibles and networks are roughly related in each dad and mom’ insurance policy — however that’s merely not the case for a lot of households.

The Kjelshuses came upon the laborious method they didn’t have a alternative about which folks’ insurance coverage was main. They could have prevented their quagmire if Mikkel had dropped his personal protection and gotten onto Kayla’s plan earlier than Charlie was born.

It’s not clear whose accountability it’s to assist households navigate these guidelines earlier than a child is born. It’s much more sophisticated for folks who’re divorced or by no means married. Insurance coverage firms don’t at all times provide the crucial data households want concerning the coordination of advantages.

“Anticipating dad and mom ought to attempt to get in contact with their well being plan earlier than the infant is born to seek out out concerning the protection guidelines,” mentioned Karen Pollitz, a senior fellow at KFF, the Kaiser Household Basis. (KHN is an editorially impartial program of KFF.)

“Additionally work out in the event that they wish to swap your entire household onto one plan as soon as the infant is born.”

It’s additionally a good suggestion to talk to human assets representatives at each dad and mom’ jobs. The start of a child is taken into account “a qualifying occasion” for insurance coverage protection in all group well being plans, so households could make selections about altering protection at the moment. In any other case, households might need to attend for open enrollment to make protection modifications.

“It’s ridiculous to me my spouse and I confronted so many points since each dad and mom have medical insurance,” Mikkel Kjelshus wrote. His daughter, Charlie, now’s coated solely by his spouse’s plan.

Invoice of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical payments. Do you’ve gotten an attention-grabbing medical invoice you wish to share with us? Inform us about it!

This story was produced by Kaiser Well being Information, an editorially impartial program of the Kaiser Household Basis.