Health insurance question: Does the birthday rule force us to upgrade to a family plan?
June 1, 2012 5:28 AM Subscribe
Insurance coordination of benefits and birthday rule question: can my wife be forced to upgrade to a family plan? Details inside.
My wife and I are expecting, and we want to put baby on my health insurance. However, my birthday is later than my wife's and both plans use the birthday rule.
We're both currently on self-only insurance plans. My employer will allow me to 'upgrade' to a family plan with no out-of-pocket cost for me, partially because my insurance premiums are a lot lower than my wife's (HDHP vs. a full-coverage PPO).
My wife's employer, however, wants $300/week from us to upgrade her to the family plan. Between childcare and the extra cost of the family plan, our expenses would easily outstrip what my wife takes home, so this isn't an option!
I thought this was straightforward: since my plan will be a family plan, and my wife's will be a self-only plan, our baby is covered by my plan only, and the birthday rule doesn't need to be used. The pediatrician's office disagrees, and says they have to bill my wife's insurance first regardless of her plan.
Is this true? Will we have to upgrade my wife's plan? Am I missing something? I deeply appreciate any help you can offer! Thanks!
My wife and I are expecting, and we want to put baby on my health insurance. However, my birthday is later than my wife's and both plans use the birthday rule.
We're both currently on self-only insurance plans. My employer will allow me to 'upgrade' to a family plan with no out-of-pocket cost for me, partially because my insurance premiums are a lot lower than my wife's (HDHP vs. a full-coverage PPO).
My wife's employer, however, wants $300/week from us to upgrade her to the family plan. Between childcare and the extra cost of the family plan, our expenses would easily outstrip what my wife takes home, so this isn't an option!
I thought this was straightforward: since my plan will be a family plan, and my wife's will be a self-only plan, our baby is covered by my plan only, and the birthday rule doesn't need to be used. The pediatrician's office disagrees, and says they have to bill my wife's insurance first regardless of her plan.
Is this true? Will we have to upgrade my wife's plan? Am I missing something? I deeply appreciate any help you can offer! Thanks!
Best answer: You can add the baby to your plan. Coordination of benefit rules only apply in a situation in which there is more than one coverage.
You may want to ask her employer if there are going to be any issues with claims for the baby for the hospital stay/birth. Usually the insurer just lumps all the claims into the mother's claims (unless there's an extended stay for the baby), but you may just want to check that there won't be any issues if the baby never gets added to the plan. Shouldn't be a problem, though.
posted by MarkAnd at 5:37 AM on June 1, 2012 [2 favorites]
You may want to ask her employer if there are going to be any issues with claims for the baby for the hospital stay/birth. Usually the insurer just lumps all the claims into the mother's claims (unless there's an extended stay for the baby), but you may just want to check that there won't be any issues if the baby never gets added to the plan. Shouldn't be a problem, though.
posted by MarkAnd at 5:37 AM on June 1, 2012 [2 favorites]
Also, babies are covered through 6 weeks on mom's plan automatically, and I know for my plan they are retroactively covered to their date of birth on whatever plan they end up on.
I also don't understand why you don't just all go on one family plan, rather than separate out like this. My family plan covers everyone in my family for the same cost. There's no cost for additional family members under the family plan. So I carry the health insurance for my family and my husband does not and gets more in his take-home pay.
What benefit is there to your wife staying on her individual plan if she can be covered by your plan?
posted by zizzle at 5:39 AM on June 1, 2012
I also don't understand why you don't just all go on one family plan, rather than separate out like this. My family plan covers everyone in my family for the same cost. There's no cost for additional family members under the family plan. So I carry the health insurance for my family and my husband does not and gets more in his take-home pay.
What benefit is there to your wife staying on her individual plan if she can be covered by your plan?
posted by zizzle at 5:39 AM on June 1, 2012
I also don't understand why you don't just all go on one family plan, rather than separate out like this.
His employer may offer an employee+1 plan which covers the employee and one other person (child or adult) but not all members of the family. This is why my wife and I are on separate plans and she has our daughter on her plan.
posted by Rock Steady at 5:54 AM on June 1, 2012
His employer may offer an employee+1 plan which covers the employee and one other person (child or adult) but not all members of the family. This is why my wife and I are on separate plans and she has our daughter on her plan.
posted by Rock Steady at 5:54 AM on June 1, 2012
Response by poster: zizzle, our self-only plans are part of the benefits packages from our employers and can't be waived for whatever reason. I guess it's because of the contract they have with the group insurer?
My employer will let me upgrade to a family plan (or in this case, a self-plus-one plan) at no cost to me, but her employer requires her to pay the difference between the self-only plan and the family plan.
posted by smurdah at 5:57 AM on June 1, 2012
My employer will let me upgrade to a family plan (or in this case, a self-plus-one plan) at no cost to me, but her employer requires her to pay the difference between the self-only plan and the family plan.
posted by smurdah at 5:57 AM on June 1, 2012
Best answer: The birthday rule *should* only apply if you have overlapping coverage. But if you just have single policies, I don't think it should apply. Mom's plan will cover her prenatal care and the birth, and then you call your insurance company and add your new child to your policy.
(The reason they can't just switch now is that group insurance plans require you to make all your changes at a certain time of the year for some reason. There are exceptions to the rule, like marriage, divorce, births, deaths, adoptions.)
posted by gjc at 6:05 AM on June 1, 2012
(The reason they can't just switch now is that group insurance plans require you to make all your changes at a certain time of the year for some reason. There are exceptions to the rule, like marriage, divorce, births, deaths, adoptions.)
posted by gjc at 6:05 AM on June 1, 2012
Response by poster: Asking this question here and getting some answers and context helped me out a lot, thanks! I was able to call the nurse back with some confidence.
She's still adamant that my wife's insurance gets billed first, but she made it sound like they'll just reject the bill every time (with "DEPENDENTS NOT COVERED" or some similar code) and then they'll bill my insurance. Sounds like a bureaucratic nightmare!
I'll start looking at a different pediatrician... waiting lists around here are crazy and the highest-rated pediatricians only accept new patients in utero!
posted by smurdah at 6:13 AM on June 1, 2012
She's still adamant that my wife's insurance gets billed first, but she made it sound like they'll just reject the bill every time (with "DEPENDENTS NOT COVERED" or some similar code) and then they'll bill my insurance. Sounds like a bureaucratic nightmare!
I'll start looking at a different pediatrician... waiting lists around here are crazy and the highest-rated pediatricians only accept new patients in utero!
posted by smurdah at 6:13 AM on June 1, 2012
Best answer: So let me get this right --- the NURSE is demanding you add FutureSmurdah to your wife's plan?!? She may deal with a lot of insurance claims, but the pediatrician's nurse is NOT an insurance expert, nor does she know all the details of your and your wife's insurance plans --- this is the purvue of your employers and HR departments.
JPD has it right: tell her to take a hike.
posted by easily confused at 6:37 AM on June 1, 2012 [1 favorite]
JPD has it right: tell her to take a hike.
posted by easily confused at 6:37 AM on June 1, 2012 [1 favorite]
Best answer: I think zizzle may be incorrect with the advice that "babies are covered through 6 weeks on mom's plan automatically."
I'm not an expert on this and would love to be corrected, but I'm pretty sure that requirements like this are imposed on a state-by-state basis, and may also vary depending on the type of insurance plan involved. So your baby may be covered for 6 weeks through mom's plan, depending on the plan and where you live. But it would be dangerous to assume this is true without doing research first.
posted by croutonsupafreak at 6:44 AM on June 1, 2012
I'm not an expert on this and would love to be corrected, but I'm pretty sure that requirements like this are imposed on a state-by-state basis, and may also vary depending on the type of insurance plan involved. So your baby may be covered for 6 weeks through mom's plan, depending on the plan and where you live. But it would be dangerous to assume this is true without doing research first.
posted by croutonsupafreak at 6:44 AM on June 1, 2012
Best answer: She's still adamant that my wife's insurance gets billed first, but she made it sound like they'll just reject the bill every time (with "DEPENDENTS NOT COVERED" or some similar code) and then they'll bill my insurance. Sounds like a bureaucratic nightmare!
This makes like zero sense. They decide which insurance company gets billed. You tell them who the covering insurance company is. If they can't handle that they are honestly completely and totally inept and I would worry about everything else they do.
posted by JPD at 6:57 AM on June 1, 2012 [3 favorites]
This makes like zero sense. They decide which insurance company gets billed. You tell them who the covering insurance company is. If they can't handle that they are honestly completely and totally inept and I would worry about everything else they do.
posted by JPD at 6:57 AM on June 1, 2012 [3 favorites]
Best answer: Perhaps you could ask the nurse what she would do if you had not provided any health insurance information for your wife. Say, for example, if she were unemployed and did not have insurance. Certainly there will be divorced couples out there where only one parent has insurance, which covers the child, and the other parent is completely uninsured. There has to be a way of dealing with that.
posted by jacquilynne at 7:28 AM on June 1, 2012
posted by jacquilynne at 7:28 AM on June 1, 2012
Does the nurse also handle billing? If not, you need to find who does and talk to them, because chances are she has no idea what she's talking about (she could be right, but that would probably be more luck then knowledge).
posted by ThePinkSuperhero at 7:52 AM on June 1, 2012 [1 favorite]
posted by ThePinkSuperhero at 7:52 AM on June 1, 2012 [1 favorite]
Best answer: She's still adamant that my wife's insurance gets billed first, but she made it sound like they'll just reject the bill every time (with "DEPENDENTS NOT COVERED" or some similar code) and then they'll bill my insurance. Sounds like a bureaucratic nightmare!
There is some truth in this. Good insurance companies will only need to update their records once a year as to whether your wife has family insurance coverage. Alas, not all companies are good and it's entirely possible that the husband's insurance will pend every single claim for the baby wanting a denial from the wife's company. It's stupid and it's a waste of everyone's time -- but it's very common.
As a former medical claims examiner, I recommend that you let the pediatrician's office send the claims to the wife insurance first in order to get their denial, then they can send the denial along with the the bill to the husband's insurance and it should get paid without any problems.
posted by rhartong at 7:55 AM on June 1, 2012
There is some truth in this. Good insurance companies will only need to update their records once a year as to whether your wife has family insurance coverage. Alas, not all companies are good and it's entirely possible that the husband's insurance will pend every single claim for the baby wanting a denial from the wife's company. It's stupid and it's a waste of everyone's time -- but it's very common.
As a former medical claims examiner, I recommend that you let the pediatrician's office send the claims to the wife insurance first in order to get their denial, then they can send the denial along with the the bill to the husband's insurance and it should get paid without any problems.
posted by rhartong at 7:55 AM on June 1, 2012
This is screwy: unless you're going to some kind of very, very small clinic, the nurse doesn't handle the billing anyway—the billing department does. And when your new baby needs to be seen, they will ask you at registration for the insurance information, at which point you will give them YOURS because that's the insurance coverage the baby will have. I really don't understand why the nurse is complicating things!
posted by Eicats at 8:52 AM on June 1, 2012
posted by Eicats at 8:52 AM on June 1, 2012
Response by poster: Although this pediatrician comes highly recommended, you've all convinced me to make sure I explore more options!
posted by smurdah at 9:57 AM on June 1, 2012
posted by smurdah at 9:57 AM on June 1, 2012
This thread is closed to new comments.
You don't need to upgrade your plan for your wife to get covered for pre-natal things. When you have the child that will constitute a change of life event an you will be able to immediately upgrade your own plan to cover the child. Why would the pediatrician be billing anyone anything before the kid is born? Maybe they are uncomfortable with your wife being on a different plan from you and child - but other than a signature from you I struggle to see why this is actually a problem.
posted by JPD at 5:34 AM on June 1, 2012 [2 favorites]