First-time parents in Texas who have two separate health insurance plans might do well to familiarize themselves with the Texas Insurance Code and U.S. Department of Labor’s insurance guidelines if they do not want to end up footing their entire labor and delivery bill.
Just ask Chris and Lauren Lewis, who got a surprise $4,160 hospital bill fourteen months after their son was born.
“I had insurance. My wife had insurance. We were double covered,” said Chris, speaking with CBS News.
He and his wife had expected that at least one of their providers would cover the birth of their child.
“We were like, ‘Are we going to have to pay out-of-pocket for this cost?’ It doesn’t make any sense,” Chris told the news outlet.
It turns out that Chris and Lauren’s insurance providers, CareFirst BlueChoice and United Healthcare, respectively, spent more than a year negotiating with Baylor Scott & White. Both companies ultimately declined to pay, each claiming it was not responsible for coverage.
Insurance providers servicing people in Texas do not all follow the same rules, especially when it comes to separately-insured couples.
“When this happens, it creates an opportunity for each insurance company to point the finger at the other,” stated Sabrina Corlette, co-founder and director of the Center on Health Insurance Reforms.
“And more often than not, the patient or the consumer falls through the cracks and gets stuck with the bill,” she added.
In Texas, three different government agencies regulate the different types of health insurance that exist.
The Texas Department of Insurance oversees state insurance plans, the U.S. Department of Labor regulates most employer-sponsored health plans, and the U.S. Department of Health and Human Services runs programs like Medicaid, Medicare, and military insurance plans.
Additionally, different insurance companies can decide whether to adopt any guidance issued by the National Association of Insurance Commissioners (NAIC).
The NAIC came up with the so-called “birthday rule,” which United Healthcare, Lauren Lewis’ insurance provider, chooses to follow. The point of the rule is to provide guidance on how insurance companies should coordinate coverage for labor and delivery.
The birthday rule states that the insurance provider covering the parent whose birthday falls first in the calendar year is responsible.
In the case of the Lewises, Chris’ birthday falls earlier on the calendar than his wife Lauren’s.
Plans regulated by the Texas Insurance Code are also required to follow the birthday rule.
Most employer-sponsored health plans, regulated by the federal government, do not have clear rules on the matter, as in the case of Chris Lewis and his provider CareFirst BlueChoice.
Baylor Scott & White recently told the Lewises it is working with CareFirst Blue Choice to resolve the issue after CBS News contacted the insurance company for comment.
