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  1. #1
    jbmb1012 is offline Junior Member
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    newborn pays a deductible?

    What is the name of your state? Illinois.

    Is this for real?? This was my 3rd child, and granted different insurances---but I questioned it because with my first two, my babies were covered under the maternity/pregnancy part of the insurance. There was nothing abnormal about our delivery/stay...etc. I went, had a baby, we both came home. And Maternity Stay and Newborn Care is covered under Pregnancy. And I paid my deductible on my first prenatal visit. So, I called our new insurance, said i felt it was a bit unusual that my newborn has to pay a deductible. The lady said that we had to pay a deductible because this was my son's first "visit" of the calendar year. Huh? I informed her that it was because he was BEING BORN...but it didn't phase her. We had a problem in the past with this insurance and my middle child and wellness visit/calendar year---where insurance was very wrong. So we contested this deductible thing. We've been round and round. HR initially said we owed nothing, then we kept getting bills....insurance recently said that the $250 is part of the hospital charge...for my newborn...not to be confused with newborn care. My husband and I went thru our insurance packet and there is a very vague description of hospital charges---we felt that the packet was not clear on how they handle newborns. We also gave them an itemized bill that shows typical newborn charges were declined due to deductible. My husband went over one HR mhead to someone else in HR who at first said we owe nothing, but is now saying there was something going on with the circumcision. That bill was paid for so I am not sure what is going on. And it specifically says that a circ is covered under newborn care. I do recall the insurance declined the circ bill because it was not specifically billed to my son's name. But, it was resubmitted and paid. I told HR to look more closely at that--but have not heard anything. So, is this a lost cause? I know at first this deductible thing seemed odd to me--and
    I questioned it...but is this odd? We are in collections now. I am thinking on paying it so that we don't tarnish our credit. Advice?
  2. #2
    xylene is offline Senior Member
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    This was my 3rd child, and granted different insurances--
    I think you have answered your own question.
  3. #3
    seniorjudge is offline Senior Member
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    Quote Originally Posted by jbmb1012
    What is the name of your state? Illinois.

    Is this for real?? This was my 3rd child, and granted different insurances---but I questioned it because with my first two, my babies were covered under the maternity/pregnancy part of the insurance. There was nothing abnormal about our delivery/stay...etc. I went, had a baby, we both came home. And Maternity Stay and Newborn Care is covered under Pregnancy. And I paid my deductible on my first prenatal visit. So, I called our new insurance, said i felt it was a bit unusual that my newborn has to pay a deductible. The lady said that we had to pay a deductible because this was my son's first "visit" of the calendar year. Huh? I informed her that it was because he was BEING BORN...but it didn't phase her. We had a problem in the past with this insurance and my middle child and wellness visit/calendar year---where insurance was very wrong. So we contested this deductible thing. We've been round and round. HR initially said we owed nothing, then we kept getting bills....insurance recently said that the $250 is part of the hospital charge...for my newborn...not to be confused with newborn care. My husband and I went thru our insurance packet and there is a very vague description of hospital charges---we felt that the packet was not clear on how they handle newborns. We also gave them an itemized bill that shows typical newborn charges were declined due to deductible. My husband went over one HR mhead to someone else in HR who at first said we owe nothing, but is now saying there was something going on with the circumcision. That bill was paid for so I am not sure what is going on. And it specifically says that a circ is covered under newborn care. I do recall the insurance declined the circ bill because it was not specifically billed to my son's name. But, it was resubmitted and paid. I told HR to look more closely at that--but have not heard anything. So, is this a lost cause? I know at first this deductible thing seemed odd to me--and
    I questioned it...but is this odd? We are in collections now. I am thinking on paying it so that we don't tarnish our credit. Advice?
    Q: I am thinking on paying it so that we don't tarnish our credit. Advice?

    A: Pay it. What you are describing is the new rule for your insurance.
    There are two rules for success:

    (1) Never tell everything you know.
  4. #4
    jbmb1012 is offline Junior Member
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    Newborn deductible?

    Right, I totally understand that every insurance is different....but if it seems ODD, why not question it. Also, with their past history---we have unlimited well care visits first year of life. They started to charge us in the new calendar year--but before my son turned 1. When I called 4 times to straighten this very simple thing up, they still didn't get it. Bottom line was we had to start paying for immunizations, which could easily be $400-500 a visit if not more. And if i would have just taken their word for it--and not stopped questioning it, I would have been dragging my kids to the local clinic to stand in line for free shots. Which I did a lot of research on to figure out how we were going to make sure my kids got immunized! Thankfully, they were wrong. It took 3 wks for HR to clear it up with them. So, I questioned this. And read our plan. Their answers are not clear. And have been different each time. We are getting charged for newborn care--which is covered under maternity. Now that they know that isn't working with us, it changed to hospital charge, and now something with the circumcision. Also, my husband even asked other people who have had children while working there---and have not heard of this. I know we should probably pay this and work on getting reimbursed---but any advice on trying to clear this matter up?
  5. #5
    averad is offline Member
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    Usually a deductible is not taken on the baby for delivery (my comment is based on policies I have reviewed and admin). The deductible is sometimes taken on lab work or pediatric services after the birth.

    It is a new policy and new benefits, review your benefit booklet and call customer services for verification. If you are unsatisfied with the CS rep ask to talk to a supervisor or request an appeal on your claim.

    I also want to make a comment on talking with your HR reps. Stop calling HR about your medical insurance call the insurance carrier who is educated in quoting and maintaining your benefits. Unless your group policy is maintained by your employer they are just going to get information incorrect or waste time. Why would you want another cook in the kitchen?

    I think its quite entertaining that the first HR rep you spoke to was, I assume, considered a meat head. Then you get to another rep who incorrectly reviews your account and continues to confuse the situation.

    From the information you have included you are responsible for the deductible.

    Things you should review(or post for review)
    1) Do you have a family maximum on your deductible and if so how much has been met? (Some policies include a maximum deductible amount a family can pay I.E $100 per person $300 Family).

    2) What exact services were applied to deductible? (Lab work, Pediatric, Maternity etc?)
    *Note: Please do not generalize maternity with pediatric or lab services.

    3) What is the exact benefit for Maternity and Well baby? (Deductible apply? Co-Pay? % of benefits?)
    Last edited by averad; 05-04-2006 at 01:56 PM.
  6. #6
    cbg
    cbg is offline Senior Member
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    As an HR practioner who has administered employer sponsored group health insurance benefits for over twenty five years, I don't know whether to be amused or annoyed by averad's assumption that no one in HR will have any clue what the benefits are. HR negotiates the benefits with the insurance carrier - why in heaven's name would you assume that they will get the information incorrect and that you are wasting time going through them?
  7. #7
    averad is offline Member
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    Quote Originally Posted by cbg
    As an HR practioner who has administered employer sponsored group health insurance benefits for over twenty five years, I don't know whether to be amused or annoyed by averad's assumption that no one in HR will have any clue what the benefits are. HR negotiates the benefits with the insurance carrier - why in heaven's name would you assume that they will get the information incorrect and that you are wasting time going through them?
    Because the member usually assumes that there is a problem before researching anything. So the member calls HR and throws a fit about benefits what is the next action that is taken? HR contacts the insurance carrier and reviews the account. Now we have a member, HR rep and probity a marketing or sales rep involved. This wastes everyone_s times and in the OPs case confusion about what the benefits really are.

    Unless the HR department can directly review the claim processing information with out calling the Insurance carrier you are just adding another layer of confusion.

    Some cases HR has to get involved but daily I see countless hours wasted on members who complain to higher powers or HR who do not understand the situation.

    Also I see that reps outside of the Insurance carrier are not educated on the rules, reviews and processes of the Insurance carrier. This causes confusion because outside reps are often confused why procedures are not covered. With a ASO group I usually see the employer asking for the claims to be paid as a exception with no reasoning. This creates confusion because the benefit hasn't changed just this case was allowed because someone complained high enough and to stop the squawking a payment was made. I frequently have HR reps tell me to pay a claim because they "feel bad" for the member (even though the service is not covered benefit and in some cases experimental).

    HR reps who are properly trained and have the necessary tools to help members are a great help, just hard to find.

    CBG I hope my explanation does not offend or upset you, I am talking based on my experience with large national groups from the Insurance carrier point of view.

    From the HR point of view I can see the Insurance carrier CS being considered under equipped or "call center" level of education. Some Insurance carriers outsource CS calls to call centers or employ low wage employees to be the face of the company. In those cases you probity will need a team of HR reps to maneuver through the bs flowing.
    Last edited by averad; 05-04-2006 at 03:31 PM.
  8. #8
    jbmb1012 is offline Junior Member
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    We always try to resolve our issues in this manner---we get a bill, we call the people who the bill is coming from--ie the hospital, get their info, then we call insurance. Usually it is just a matter of us being a go between to get it figured out. But, if we feel after enough attempts have been made to resolve the matter, we enlist HR to help. They know the plan, and who to call...and can even explain things. They are a good neutral go between.

    With our first problem---the insurance people were USELESS. And quite honestly, when they are right, you are very wrong and they won't even listen. And HR was extremely helpful in resolving that matter.

    With this deductible thing--the insurance people were useless again. We enlisted HR almost immediately. But, HR dropped the ball too. HR said we didn't owe, but didn't follow thru. We got a bill and sent them a follow up, a wk later sent another follow up. My husband and I have sent them itemized bills, and follow ups asking if they need more info. Isolated incident--not sure---but I am really upset that it is in collections. HR has also given us different answers. Twice we were told we didn't owe. And now it is something else. If this is simple enough, there should have been a simple answer immediately. Women have babies all the time.
  9. #9
    averad is offline Member
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    We always try to resolve our issues in this manner---we get a bill, we call the people who the bill is coming from--i.e. the hospital, get their info, then we call insurance.
    Music to my ears

    Usually it is just a matter of us being a go between to get it figured out. But, if we feel after enough attempts have been made to resolve the matter, we enlist HR to help.
    Correct you shouldn_t have to deal with bad CS at your Insurance carrier. Remember that CS supervisors are available and a good step before contacting HR.

    They know the plan, and who to call...and can even explain things. They are a good neutral go between.
    In your case you say they know the plan however they cannot properly quote your maternity benefits or review your claims. It seems they are further confusing the matter as you still have no idea what services were applied to deductible.

    With our first problem---the insurance people were USELESS. And quite honestly, when they are right, you are very wrong and they won't even listen. And HR was extremely helpful in resolving that matter.
    Are you talking about your 2nd child and the issues you had then? CS reps that take on a god complex should be reported to a supervisor as this is not good customer service. If you have to call more then once your not receiving a level of service that I consider adequate (First call resolution & customer satisfaction is my number 1 priority).

    With this deductible thing--the insurance people were useless again. We enlisted HR almost immediately.
    What steps were taken with the Insurance carrier to review your case? Was a supervisor involved? Did you request any documentation to review (I.E explanation of benefits, copies of your benefits).

    But, HR dropped the ball too. HR said we didn't owe, but didn't follow thru. We got a bill and sent them a follow up, a wk later sent another follow up. My husband and I have sent them itemized bills, and follow ups asking if they need more info.
    If HR has to request information from the Insurance carrier you are just adding another step to the process.

    Isolated incident--not sure---but I am really upset that it is in collections.
    claims do not go to collections usually for a few months after the services. With a large hospital I usually find that claims can sit unpaid for 4 to 6 months without beeing sent to collections. Now that statement was based on what I have seen. When was your baby born and how long have you know about this bill? If your answer is that you have been working on it for a few months its no suprize its in collections and you could have paid the $250 and been paid back to save yourself all the credit issues.

    HR has also given us different answers. Twice we were told we didn't owe. And now it is something else. If this is simple enough, there should have been a simple answer immediately. Women have babies all the time.
    This is why I say to deal with the Insurance carrier directly through Supervisors and review processes. Your HR reps do not seem to have the ability to review your policy, claims and issues without extra steps through the insurance carrier.

    If you post the information I requested I may be able to explain what happened with your policy. however the Insurance CS should be able to review your policy and explain your benefits. If not ask for a supervisor if that_s no help then get a conference call in place with You, Hr and a CS supervisor.

    Also if your Insurance carrier has a webpage you may be able to log in and review your claims information and benifits. You then should be able to review claims,benifits etc using their webportal. unfortunetly some carriers have not made systems like this avalible to members yet.
    Last edited by averad; 05-04-2006 at 03:28 PM.
  10. #10
    cbg
    cbg is offline Senior Member
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    For you to blindly assume that no one in HR has any knowledge of the policies they administrate and that any information provided by HR is going to be incorrect and the waste of everyone's time, you're damned right I find that offensive.
  11. #11
    jbmb1012 is offline Junior Member
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    You may have had luck dealing with insurance carriers. I have not, supervisor or not--I always seem to run into a dead end. And I have not had the best of luck dealing with HR--but I usually find that when I put them head to head--it helps. I think most people will deal with insurance first---and as long as they can. Which is what we did. I found them very "matter of fact"....and with this--"i don't see what the problem is".

    1) Do you have a family maximum on your deductible and if so how much has been met? (Some policies include a maximum deductible amount a family can pay I.E $100 per person $300 Family). Yes, there is a family deductible. It was not met. I already surmised this was where the $250 deductible was coming from--and being the honest person I am--I even asked them. And they told me it was because it was my son's first visit in the calendar year. Which was a ridiculous answer. Then, the next thing was that it was a hospital charge, then something with the circumcision....this is all coming from the insurance.

    2) What exact services were applied to deductible? (Lab work, Pediatric, Maternity etc?)
    *Note: Please do not generalize maternity with pediatric or lab services. I do not have the itemized bill in front of me anymore---but it was all newborn care and nursery charges, circumcision...etc. This is what my plan says...Newborn Care. Newborn well baby care for Hospital nursery charges, in-Hospital doctor visits and circumcision.

    3) What is the exact benefit for Maternity and Well baby? (Deductible apply? Co-Pay? % of benefits?) Under PREGNANCY--100% after deductible. I paid my deductible at my first prenatal visit.

    Pregnancy. Treatment of pregnancy for Participant or spouse.
    a. Maternity Stays. Coverage for a Hospital stay following a normal
    vaginal delivery will be 48
    hours for both the mother (if a Covered Person) and the newborn child
    unless a shorter stay
    is agreed to by both the mother and her attending Physician. Coverage
    for a Hospital stay in
    connection with childbirth following a Cesarean section will be 96 hours
    for both the mother (if
    a Covered Person) and the newborn child unless a shorter stay is agreed
    to by both the
    mother and her attending Physician.
    b. Pre-natal Care. Pre-natal standard tests (not to include genetic
    testing) and one routine
    ultrasound will be considered an Eligible Expense, per period of
    pregnancy.
    c. Newborn Care. Newborn well baby care for Hospital nursery charges,
    in-Hospital doctor
    visits and circumcision.


    My question is...why does my newborn have a deductible? His STAY and newborn care was covered under pregnancy. To which I met my deductible. He was result of my condition. Why on earth does he have to pay a deductible? Just seems absurd. They said it was hospital services--his, but for some reason aren't saying that anymore. There is no other mention of newborn or birth of a child--anything in any other pages of this insurance plan. There is one part that states if 2 or more family members are injured in the same accident---only one deductible will be applied. I find it odd that it explains that--but no where does it say, when giving birth, the child or children will then have to pay a deductible. Or, if the family deducitible is not met...blah blah blah. Anyway, thanks....
  12. #12
    averad is offline Member
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    Services for the child after the birth after processed under the newborn. Once the child is born he/she is her own person. So services for lab, surgery or pediatric (etc) would apply to the deductible unless specifically stated in the benefits.

    You son is his own person and services for him are to be applied to his deductible.
  13. #13
    jbmb1012 is offline Junior Member
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    newborn care, wellness...circumcision...stay is covered. i guess i don't see where he incurred a bill that was not covered. under the standard care.
  14. #14
    averad is offline Member
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    Quote Originally Posted by jbmb1012
    newborn care, wellness...circumcision...stay is covered. i guess i don't see where he incurred a bill that was not covered. under the standard care.
    The services are not beeing denied they are applied to the major medical deductible on the member receiving services (The child once born is consitered a dependant under the policy and no longer part of the mother. Services are then processed under the childs coverage at 100% after deductible).

    Standard Administration: (This is not from a benefit booklet this is taken from a medical policy manual internal to a Insurance Carrier).
    The Newborn Care charges are paid under the baby's own coverage. The mother is not required to be covered for the Newborn Care to be eligible.

    I hope this clarifies why you are beeing charged, if not please explain your confusion and I will do my best to clarify.

    Quote Originally Posted by jbmb1012
    You may have had luck dealing with insurance carriers. I have not, supervisor or not--I always seem to run into a dead end. And I have not had the best of luck dealing with HR--but I usually find that when I put them head to head--it helps. I think most people will deal with insurance first---and as long as they can. Which is what we did. I found them very "matter of fact"....and with this--"i don't see what the problem is".
    I am amazed that no one is able to review your policy and give you a direct answer. Based on what you have provided my answer should be correct and if you call customer service I hope they can verify (please do verify my information).

    Quote Originally Posted by jbmb1012
    There is one part that states if 2 or more family members are injured in the same accident---only one deductible will be applied. I find it odd that it explains that--but no where does it say, when giving birth, the child or children will then have to pay a deductible. Or, if the family deducitible is not met...
    Please do remember that a benefit booklet can only hold so much information, not everything makes it into the book. You may want to provide feedback to your employer that the benefit booklet may want to be reviewed and republished. A see a fair ammount of employers use benefit books for years (I have one book on my desk that is from 1999 and has not been updated to reflect benefit changes. The employer does not want to pay for the books to be published or delivered to members).
    Last edited by averad; 05-04-2006 at 06:30 PM.
  15. #15
    jbmb1012 is offline Junior Member
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    I am not confused and I never said the servicies were denied. You are simply stating everything my husband and I have already discussed, considered and covered. This plan says very clear--newborn care, maternity stay for mother and newborn, circumcision are covered once the deductible was met for pregnancy. That's me. I paid my deductible. What else are they charging him for--that he has to pay a deductible? No one knows, they just say we owe it.

    Thanks for you input.

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