<figure>
 <img src="https://media.eaglewebservices.com/public/2021/1/1611856961625.png" alt="Mikkel and Kayla Kjelshus' daughter, Charlie, had a complication during delivery that caused her oxygen levels to drop and put her at risk for brain damage. Charlie needed seven days of neonatal intensive care, which resulted in a huge bill — $207,455 for the NICU alone — and confusion over which parent's insurer would cover the little girl's health costs. Christopher Smith / Kaiser Health News " />
 <figcaption>Mikkel and Kayla Kjelshus' daughter, Charlie, had a complication during delivery that caused her oxygen levels to drop and put her at risk for brain damage. Charlie needed seven days of neonatal intensive care, which resulted in a huge bill — $207,455 for the NICU alone — and confusion over which parent's insurer would cover the little girl's health costs. Christopher Smith / Kaiser Health News </figcaption>
 </figure>By CARA ANTHONY <a href="https://www.kcur.org/health/2021-01-28/birthday-rule-blindsides-first-time-olathe-parents-with-a-mammoth-medical-bill">Kaiser Health News</a>In the nine months leading up to her due date, Kayla Kjelshus and her
 husband, Mikkel, meticulously planned for their daughter's arrival.Their
 long to-do list included mapping out their family's health insurance 
plan and registering for baby gear and supplies. They even nailed down 
child care ahead of her birth."We put a deposit down to hold a spot at a local day care following our first ultrasound," says Kayla Kjelshus, of Olathe, Kan.The
 first-time parents felt ready for their daughter's debut on Feb. 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 
delivery that caused her oxygen levels to drop and put her at risk for 
brain damage."We had a waiting room filled with family and 
friends," Mikkel recalls. "To come out and say things aren't well ... it
 was really hard."Charlie was transferred from Saint Luke's 
Community Hospital to HCA Overland Park Regional Medical Center, where 
she received treatment in the neonatal intensive care unit, known as the
 NICU, for the next 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 plan through Blue 
Cross and Blue Shield of Kansas City. 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.<figure>
 <img src="https://media.eaglewebservices.com/public/2021/1/1611857026650.png" alt="For Charlie Kjelshus, “the birthday rule” meant that dad Mikkel’s plan ― with a $12,000 deductible, a high coinsurance obligation and a network focused in another state ― was deemed her primary coverage after her NICU stay as a newborn. Mom Kayla’s more generous plan was considered secondary coverage." />
 <figcaption>For Charlie Kjelshus, “the birthday rule” meant that dad Mikkel’s plan ― with a $12,000 deductible, a high coinsurance obligation and a network focused in another state ― was deemed her primary coverage after her NICU stay as a newborn. Mom Kayla’s more generous plan was considered secondary coverage.</figcaption>
 </figure>The Patient: Charlie Kjelshus, an infant covered by her 
mother's plan through Blue Cross and Blue Shield of Kansas City and, 
eventually, her father's plan, CommunityCare of OklahomaMedical Service: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743149/" target="_blank">Whole body cooling</a> and other treatment in the NICU to prevent brain injury that may result from oxygen deprivation during birthService Provider: HCA Overland Park Regional Medical Center in Overland Park, Kan.Total Bill: Multiple charges totaling $270,951, according to Mikkel Kjelshus, including a charge of $207,455 for the NICU stayWhat Gives:
 Kayla Kjelshus filed a claim with Blue KC, and the insurer started 
paying for baby Charlie's care. But then it canceled payments to the HCA
 Overland Park hospital, St. Luke's Community Hospital and Charlie's 
neurologist, pediatrician and other physicians."We thought, 'This is crazy,'" Mikkel says. "'We have insurance.'"What was going on?The
 Kjelshus family had slammed into something well known among insurance 
experts but little understood by the general public. "Coordination of 
benefits" and "the birthday rule" are the jargon terms for the red tape 
that snared them.When a child is born into a family in which both
 parents have insurance through their jobs, the parents are supposed to 
"coordinate benefits'' — meaning they must tell both insurers that their
 child is eligible for coverage under two plans. The parents might be 
forgiven for thinking they have some say in how their child will be 
insured. In most cases, they don't.Instead, a child with double 
health insurance eligibility must take as primary coverage the plan of 
the parent whose birthday comes first in the calendar year; the other 
parent's insurance is considered secondary. This model regulation was 
set by the National Association of Insurance Commissioners and adopted 
by most states, including Kansas, says Lee Modesitt, director of 
government affairs with the Kansas Insurance Department.For 
Charlie Kjelshus, the birthday rule meant her dad's plan — with a 
$12,000 deductible, high coinsurance obligation and a network focused in
 a different state — was primary. Her mom's more generous plan was 
secondary.Mom Kayla says Blue KC dispatched an investigator to 
discover that dad Mikkel had insurance through his job. The family had 
not been trying to hide Mikkel's coverage; they merely weren't aware of 
the birthday rule and that they may be subject to state laws that ensure
 babies are covered <a href="http://www.kslegislature.org/li_2016/b2015_16/statute/040_000_0000_chapter/040_002_0000_article/040_002_0102_section/040_002_0102_k/" target="_blank">for the first 31 days of life</a>."If
 these are the rules of engagement, you need to tell people upfront that
 these are the rules," says Dr. Linda Burke, OB-GYN and author of The Smart Mother's Guide to a Better Pregnancy. "It's a communication problem."After
 Blue KC informed Mikkel that his insurance had to serve as primary 
coverage, CommunityCare of Oklahoma did pay Charlie's bills to the 
hospitals and other providers. It paid HCA Overland Park $16,605 on the 
$207,455 NICU charge. The insurer said its negotiated rate on the bill 
was $35,721. With Mikkel's 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 baby is in the NICU, then it's a red 
flag," Burke says. "They are going to look for ways to cut their 
losses."Resolution: The couple turned to the Kansas 
Department of Insurance to file a complaint about the bill, but the 
department declined to help because Kayla's policy is self-funded by her
 employer, which means the company is subject to federal rather than 
state regulations.After close 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' bill as a secondary insurer and said the 
Kjelshuses should not be responsible for what HCA Overland Park said was
 a remaining balance of $7,504.51. But the family kept getting bills.And, beginning in summer 2020, collections calls from the hospital rolled in daily, leaving the couple frustrated and confused.Eventually,
 after a human resources officer at Kayla's job stepped in to help, they
 received a statement with a zero balance. Their own calls to HCA 
Overland Park hospital billing department didn't get them anywhere."We always got a different answer," Kayla says. "It was so frustrating."A spokesperson for the hospital apologized for the deluge of calls from collections."We
 made an administrative error and an automated billing call system for 
payment occurred, causing the family undue frustration during an already
 stressful time, and we apologize," the hospital wrote in a statement. 
"Once the issue was identified and resolved, the insurance companies 
processed the claim and we informed the family that there is a zero 
balance on the account. Again, we are sorry for the stress and 
inconvenience, and wish them well."In a statement, Blue KC 
acknowledged that coordination of benefits can be confusing for members 
and that the company follows rules of state and federal regulators, 
modeled on standards set by 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's bill as they were 
supposed to: The primary insurer paid first, and the secondary paid what
 had not been covered by the first. But it took more than a year of 
phone calls, appeals and complaints before the Kjelshus family had the 
matter settled. Charlie turns 2 next month.<figure>
 <img src="https://media.eaglewebservices.com/public/2021/1/1611857078503.png" alt="First-time parents Mikkel and Kayla Kjelshus felt ready for their daughter’s debut on Feb. 15, 2019, but they weren’t ready for a scary complication that landed daughter Charlie in the NICU for her first seven days of life ― nor were they ready for the red tape surrounding “the birthday rule,” designating which parent’s insurance would cover the hefty bill." />
 <figcaption>First-time parents Mikkel and Kayla Kjelshus felt ready for their daughter’s debut on Feb. 15, 2019, but they weren’t ready for a scary complication that landed daughter Charlie in the NICU for her first seven days of life ― nor were they ready for the red tape surrounding “the birthday rule,” designating which parent’s insurance would cover the hefty bill.</figcaption>
 </figure>The Takeaway: In theory, "the birthday rule" would be a fair, 
if random, way to figure out which insurance should be 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 — but that's simply 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's plan before Charlie was born.It's not 
clear whose responsibility it is to help families navigate these rules 
before a baby is born. It's even more complicated for parents <a href="https://selecthealth.org/-/media/selecthealth82/pdf-documents/fehb-plan-documents/2017-naic-and-coordination-of-benefits.ashx" target="_blank">who are divorced or never married</a>. Insurance companies don't always offer the critical information families need about the coordination of benefits."Expecting
 parents should try to get in touch with their health plan before the 
baby is born to find out about the coverage rules," says Karen Pollitz, a
 senior fellow at KFF, the Kaiser Family Foundation. (KHN is an 
editorially independent program of KFF.)New parents should "also figure out if they want to switch the entire family onto one plan once the baby is born."It's
 also a good idea to speak to human resources representatives at both 
parents' jobs. The birth of a baby is considered "a qualifying event" 
for insurance coverage in all group health plans, so families can make 
decisions about changing coverage at that time. Otherwise, families 
might have to wait for open enrollment to make coverage changes."It
 is ridiculous to me my wife and I faced so many issues since both 
parents have health insurance," Mikkel Kjelshus says. His daughter, 
Charlie, now is covered only by his wife's plan.Bill of the 
Month is a crowdsourced investigation by KHN and NPR that dissects and 
explains medical bills. Do you have an interesting medical bill you want
 to share with us? Tell us about it!

'Birthday rule' blindsides Kan. parents with mammoth medical bill