'Birthday Rule' Blindsides First-Time Parents With A Mammoth Medical Bill
ARI SHAPIRO, HOST:
Every month, NPR and Kaiser Health News take a close look at medical bills that you send us. And today, we have one about something called the birthday rule. Dr. Elisabeth Rosenthal is here to tell us about it. She's editor-in-chief of our partner, Kaiser Health News.
Hi there.
ELISABETH ROSENTHAL, BYLINE: Hi. Nice to be here again.
SHAPIRO: A birthday rule sounds fun but given that this is the Bill Of The Month segment, I'm guessing it isn't. What is it?
ROSENTHAL: (Laughter). Right. This is no happy birthday. It was a big, unpleasant surprise for the family who had a new baby we're about to meet.
SHAPIRO: OK, tell us about that family.
ROSENTHAL: Mikkel and Kayla Kjelshus are a young couple who live in a suburb of Kansas City. They have one child, a little girl named Charlie, who's almost 2 now.
SHAPIRO: OK, well, reporter Stephanie O'Neill heard from Mikkel and Kayla and even Charlie for this story. So, Dr. Rosenthal, stay with us, and let's listen to her report.
STEPHANIE O'NEILL, BYLINE: It's bath time for little Charlie Kjelshus. And on this particular night, her dad, Mikkel, is the parent in charge.
(SOUNDBITE OF ARCHIVED RECORDING)
CHARLIE KJELSHUS: Dada.
MIKKEL KJELSHUS: Yeah, baby?
C KJELSHUS: He's upside-down?
M KJELSHUS: Yeah, he's upside-down.
M KJELSHUS: This evening ritual at the Kjelshus' home in Olathe, Kan., is among the many Mikkel his wife, Kayla, imagined as they eagerly awaited their daughter's birth. And like many first-time parents, they tried to prepare for nearly everything.
KAYLA KJELSHUS: As soon as we had our first ultrasound, which was at seven weeks, we put down a deposit on day care.
O'NEILL: But they didn't anticipate little Charlie experiencing a respiratory complication during birth that caused her oxygen level to plummet dangerously low. Mikkel remembers a frenzy of activity suddenly filling their hospital room.
M KJELSHUS: It went from just a couple of people to 10-plus people fast. As soon as we cut the umbilical cord, they took Charlie, and they started working on her. That was probably one of the most frightening times of my life.
K KJELSHUS: It was just extremely scary to be laying there, not be able to do anything.
O'NEILL: Doctors ordered an ambulance to race Charlie to the neonatal intensive care unit at the nearby regional medical center. Charlie spent her first seven days of life there, receiving whole-body cooling, a treatment that ultimately saved her from brain damage. Mikkel says relief washed over the couple when they got the MRI results.
M KJELSHUS: She did really good. Her MRI ended up being positive. It was great. It was great news.
O'NEILL: Charlie's care wound up costing nearly $300,000. Kayla, a nurse practitioner who has great health insurance through her work, wasn't worried. In fact, her Blue Cross Blue Shield insurance plan quickly cut checks to all the providers. But then an arcane industry policy called the birthday rule messed it all up. Turns out when a child is covered by both parents' insurance, the parent whose birthday comes first is the primary policyholder.
K KJELSHUS: And because his birthday came before mine - two weeks before mine - he becomes the primary.
O'NEILL: But Mikkel, who works as a salesman, has a barebones insurance policy with a $12,000 deductible. And it was that insurance plan that had to come first, Kayla says.
K KJELSHUS: So then we started getting thousands and thousands of dollars' worth of bills in the mail because Blue Cross Blue Shield has retracted every payment they made.
O'NEILL: The couple spent months after Charlie's birth on the phone, ping-ponging between the insurance companies, hospitals and collection agencies. Ultimately, the human resources office at Kayla's work helped, and that led to both insurance companies finally paying all the bills.
K KJELSHUS: When my husband first told me that it was, you know, zero dollars - we don't owe anything - I mean, I started crying. I mean, I was bawling because I thought, finally, we were at the end of this long, drawn-out road that I honestly wasn't sure was ever going to end.
O'NEILL: Mikkel says he, too, is relieved that when they celebrate Charlie's second birthday next month, all of this will be behind the Kjelshus family.
C KJELSHUS: (Babbling). Bye-bye.
O'NEILL: For NPR, I'm Stephanie O'Neill.
SHAPIRO: And Elisabeth Rosenthal is still here with us.
Dr. Rosenthal, in that case, it seemed like it worked out in the end, but it was a lot of headache to get there. Explain what was going on.
ROSENTHAL: Well, what we're seeing here is something called the birthday rule, which is part of something called coordination of benefits - insurance speak. And that means you're supposed to tell both insurance companies about the coverage your family has when you have a new baby. It mostly kicks in when a family is eligible for plans by two different employers or groups.
And you know, basically, the birthday rule means patients don't have a choice in which spouse's insurance is primary when they have a kid, unless they know how to play the game. You can choose your kid's name. You can choose a doctor. But not the insurance. Whose birthday comes first in the calendar year, that will be the plan that covers your baby.
SHAPIRO: Is there anything they could have done differently?
ROSENTHAL: It's about knowing how to play the insurance game. In this family's case, they might have decided on an easier path if they had all gotten on one plan before the baby was born - that's Kayla's plan - and actually declined the second insurance policy, the husband's coverage, which wasn't so good. That way, there wouldn't have been two plans at play. Now, you do lose something with this because the secondary coverage often will pay the leftover bills that the primary didn't. But in this case, it just caused confusion and havoc at the same time as this couple was trying to adjust to a new baby.
SHAPIRO: Dr. Elisabeth Rosenthal, thank you so much for being here with us today.
ROSENTHAL: Thanks. This insurance thing can be a minefield for patients.
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