Don't have your baby in December either

The open enrollment blues.

On Monday, we heard from Michael Kimball, an Oklahoma man whose baby was born just two weeks into January—timing that cost him hundreds of dollars, because our friend the deductible resets at the start of the year. The hospital also asked him for an upfront payment of $1280 while his wife was giving birth, which turned out to be erroneous. The moral of this story is that the American health insurance system makes giving birth, what should be one of the most natural human processes (and rights) imaginable, a nightmare. The arbitrary calendar of health insurance sits its humungous ass right on top of your life, no matter what your other plans were.

But having your baby in January isn’t the only way insurance can get in your way, as our subject today discovered. It can also happen when your baby arrives in December.

Patrick, a Florida man whose wife was expecting their first child in 2014, thought he had figured out how to pick his insurance plans; after all, he did work for a benefits management company. He knew his wife would need a lot of healthcare that year—they needed fertility treatments, plus the usual checkups and the actual birth—so he picked the more expensive Gold plan for that year. Patrick said the cost of this plan came to about 20% of his pay for that year, though it still had a deductible of a couple thousand dollars. Then, the idea was that he would drop to Silver for the next year, because (assuming the baby was healthy) they would only need wellness checks that should be covered on whatever plan.

The baby was born on December 3, 2014; she needed a few days in the NICU, but didn’t seem to have any chronic or ongoing health needs, and the Gold plan should cover those expensive days in the hospital. He waited to receive her Social Security Number and added her to his plan in January, thinking that would ensure they were all on the Silver plan going forward (and that the Gold coverage he paid for in December had already paid for the birth), and went about his life. The plan was working.

Until it wasn’t. Months into his daughter’s life, they started getting new bills from the hospital, even though they had already paid their bills months ago. The hospital said he had changed his benefits. Bills totaling more than $10,000 were piling up. Patrick was confused; he thought he had only switched down to Silver for 2015, and the previous December was very much in 2014.

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Patrick discovered that when you enroll in an insurance plan during a “qualifying life event,” the coverage dates back to the event itself, not the date you change the coverage. A qualifying life event is something like a birth, divorce, or loss of a job, allowing you to change your coverage outside of the normal open enrollment window; the idea of this is to prevent people switching to better plans or buying insurance at all only when they actually need healthcare, known as ‘adverse selection.’ Patrick had picked a Silver plan when he enrolled her—they’re all on the same plan, and that was the plan he wanted for 2015—which then changed his coverage level for December, even though he had already paid his expensive Gold premium for that month and paid the bills associated with the birth.

Once Patrick’s baby was born in December, his plan was shot; if he wanted the birth to be covered on his plan, and he wanted to be on Silver for the next year, he had to switch down, leading to thousands of dollars in extra bills. If she had been born a month early, she could have been added to his Gold plan for that year, and they could all have switched to Silver during open enrollment, which ended for him before his wife gave birth.

After months of frustrating calls with his employer and his insurer, Patrick’s mom got involved. Thanks to her contacts at Patrick’s company from her own career, a letter she wrote to him demanding they fix it (and threatening to go to the media) worked; the plan coverage was switched from Silver to Gold for that month, and the bills were covered. Turns out they could, in fact, easily address the problem they claimed was impossible to fix. This was a very lucky close call for Patrick, who made around $45,000 annually; after premiums in the thousands of dollars that year, plus all the other costs of having a child, where would he get more than $10,000 to pay off bills?

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It’s easy to say Patrick should have just known how insurance enrollment works. But he was screwed either way. If he had paid up for the Gold plan for 2015 to get those December bills covered, he’d be stuck paying a much higher premium for the rest of the year when he didn’t need the better coverage. (And they wouldn’t refund him for the difference between his Silver and Gold premium for December 2014, of course.) Pick the Silver plan, and the hospital gets to bill him thousands of dollars. As often ends up being the case in American healthcare, you can’t really control what you pay, only when you pay it. After all, all that money has to come from somewhere.

Stories like this are just another example of how private insurance is a bad way to pay for a healthcare system. If you want to offer lots of different plans at different coverage levels, to maintain the fiction that people should only have to pay for the amount of care they anticipate needing (and that they can anticipate that care accurately), then you end up with problems like this. The sick individualism at the heart of American healthcare insists that we ensure as many people as possible are responsible for their own healthcare costs; that’s how we end up with cancer patients going bankrupt and people skipping expensive prescriptions. The only way we can keep this bad system running, instead of spreading out costs evenly through taxation, is through cruelty, punishment, and pain. There’s no way to do this right. We just have to get rid of it.

This interview has been edited and condensed.

Patrick: In 2014, I was working at a benefits outsourcing company. Despite being a benefits outsourcing company, their benefits are actually pretty shitty, though we always had the choice of a bunch of Blue Cross Blue Shield plans. Their plans range from "bronze" to "platinum." My wife and I were trying to have a baby at the time. We had to do a bunch of fertility stuff because we were having trouble conceiving, and also, if we got pregnant, we would have to go to the hospital, have a baby, all that kind of stuff. So I moved us from the silver plan to the gold plan for Blue Cross Blue Shield. The idea was, if we have a baby, we're going to spend, like — the premiums that I had to pay for this gold plan was ridiculous, it was $8,000 or $9,000 [per year] even being an employee, like an employer health care plan. But the cost savings for being in the hospital and the birth costs were way better than the silver plan.

We mapped out like all the different costs, and we decided it would be worth it to pay for that. So we paid for the gold plan for 2014. We ended up conceiving, great. And then our daughter was born in December, which was unfortunate for us. It's after open enrollment has closed, and it's right before the rollover to the new year. She was born December 3. There's a rule in U.S. healthcare where your child does not have to be added as a beneficiary on your healthcare plan for, it's either 30 days or 60 days. I'm pretty sure it's 60 days because I added her in the middle of January. But it's basically like, you don't have to actually go into your plan and do anything. The child is automatically covered.

So my plan was, for the next year, we're going to drop back to the silver plan because we should only be doing checkups. The healthcare plans usually cover all the wellness checks for babies, and we didn't anticipate needing anything further. This is also the great thing about American healthcare, where you have to decide, 'Do I think my child is going to have some chronic illness? Should I'd be prepared for that?' Things like that. So we planned to drop to the silver plan for the next year.

Before my wife even had the baby, we had to complete our open enrollment. So I went to silver — that would be for the 2015 year — but I was still on gold until December 31. We had the baby. My wife's labor was really long, and then my daughter had to stay in the NICU for a week. So we had to stay in the hospital an extra day to begin with, just off of my wife's labor, and then we had to stay an extra five to seven days in the hospital. We were staying at Winnie Palmer, which is one of the better children's hospitals. Despite this hospital being the third best hospital, supposedly, for childbirth in the United States, they didn't have enough doctors the night that my wife was actually having the baby. At one point, the nurse like, pointed to me and said, 'You come over here and help me do something.' So I had to go around to the other side and help the baby come out, which, I'm pretty sure that's not standard. But that was a pretty harrowing experience. It's not going to leave my brain. And then the nurses themselves were not that nice to my wife, so she didn't have a very good time.

So we ended up staying in the hospital for this extra five to seven days. We're eating hospital food, and it's shitty. And then obviously, my daughter is just born and she has to stay in this special NICU thing. It's not like she was born premature either. They wanted to monitor her because she had low oxygen levels and stuff. And I was like, 'Oh, boy, thank God I got this gold plan!' Because we just stayed in the hospital for an extra seven days, in the NICU, which is an expensive thing.

Eventually, we went home and we got all the hospital bills. I think we ended up paying something like $1,000 for everything. And you know, it's good to see the hospital bill where it's like, 'Oh yeah, you stayed in the NICU for five days, here's $50,000 that you have to pay. Oh, your insurance covered $49,000 of it, so you only have to pay the $1,000.' So that was good. And then I waited until after January 1. My last paycheck for that year had gone through, so I'd paid 100% of my premium for this gold plan.

And then sometime in mid-January, I went on the website, and for adding people in the United States healthcare system, you have what's called a "life event." The life event was, in our case, a child. It could be you had a home disaster or something. Sometimes they let you do that stuff, and you can actually change your healthcare. Otherwise, you're locked in for whatever you've picked at that time. I did a life event on the website, and I went through and added my daughter into the website as a beneficiary. We had to wait for her Social Security Number too, which is probably why they do that rule where they can be on your insurance for 30 or 60 days. So we had her Social Security Number, and I went and added her on there. I had my silver plan and I added her, but her birthday was December 3 of the previous year.

What I didn't realize is the life event is effective from her birthday, not from the date that I'm adding it. I didn't think anything of it. I still had my silver plan, and she was added on it, and we were going to doctor's appointments. It was fine. And then in May or June of that year, we started getting these hospital bills from the hospital—even though we had already gotten all the bills and paid them—saying, 'Due to a change in the insurance benefits, you now owe' whatever amount. We had gotten a couple of these, and they were for a couple thousand dollars each. I didn't pay them. I was like, 'What's going on here?'

That's when I started to investigate. I called Blue Cross Blue Shield, and I'm like, 'Hey, I'm getting these hospital bills way after we were in the hospital, and I've already gotten bills that said I paid in full.' And they said, 'Well, your work changed your benefits, so as of December 3, you went from the gold plan to the silver plan.' And I was like, 'Well, OK. That doesn't sound right. Let me go call my work.' And so I called: 'Blue Cross Blue Shield told me that you changed my benefits for last year?' And they were like, 'Yes, sir, you had your life event and you added your daughter to your insurance.' Blah, blah, blah. And I'm like, 'Well, yeah, I wanted to add her to my insurance for this year, which I'm using the silver plan. Can you fix that?' And they're like, 'Oh no, we can't change that because it's a life event. You have to talk to the insurance company and work it out with them.'

At that point, I was getting really anxious. I was also getting called by the hospital, and they were saying they were going to send collections people after me. They're like, 'Pay the bill.' I was yelling at them, too. I was like, 'First of all, you sent me these bills. It's not like I've been delinquent.' I had already paid all the bills in February or March or whatever. You can't send me a bill and then literally a week later say you're going to send me to collections. I don't think that's how bills work. But from their point of view, it looked like I was delinquent from six months ago. That was when my actual visit was.

I started having these phone calls back and forth with everyone, and it became clear to me that the way that the system works is fucked up and stupid, and no one wants to take any responsibility whatsoever for the system being that way. I would tell the insurance company, 'I had the gold plan for the entire year of 2014. You need to administer my benefits as if I had the gold plan. I paid the entire premium. They came out of my paycheck every single month until the end of the year. You have to give me this plan. It's what I paid for. I want to get the benefits that I paid for.' And they were like, 'But you changed it, so we have to honor the change.' And I'm like, how would that make any sense? Why would someone pay an entire year's worth of premiums for an expensive plan and then change to a worse, shittier plan that then incurred them hospital bills? It doesn't make any sense.

They wouldn't fucking fix anything. I was trying to tell my work, 'You guys have to send them something because they're not willing to do anything about it, and you guys can. First of all, you're my job, you should be helping me here.'

It was really annoying because I worked on the system. I knew all the database tables where all this information is stored. I couldn't see our employer one, I was working for other companies; there's a special team that worked on our company's version to keep it all separate. But I could tell them exactly where to go in the system to fix it. I was telling them, 'Yeah, you go to this table and change the start date and the end date, and then send the new ETL load to Blue Cross Blue Shield for that.' Like, 'That's all you've gotta do. I know exactly what you guys need to do, so you can fix it.' And they were like, 'We're not authorized to do that.' And I was like, 'Well, OK, I know you're authorized to do that. I know like five people personally who are authorized to do it. You could do it.'

The worst it got was when I would conference in my work and Blue Cross Blue Shield and explain to them both on the phone at the same time what exactly the problem is, how either of them could fix it, and could you two please work together to just solve this issue for me? And they would just not fucking do anything. At one point—I'm going to yell, so if you want to move your phone, I'm going to also move my phone away—but one point I was just on the phone, and I was like, 'WILL SOMEBODY FUCKING HELP ME?' That did not garner any sympathy whatsoever. This is after hours of calling them individually, conferencing them in to each other, doing all this stuff.

So eventually—my mom worked for Darden Restaurants. She had worked there for 30 years or something, so she was almost like a director, and she knew a lot of the high-up people in the company. So she wrote a letter for me to my CEO at the time explaining this whole situation. She wrote this letter where we were like, 'You really have to fix this or we're going to talk to the Orlando Sentinel. You have to change this. This is outrageous.' Miraculously, once we wrote this letter, oh, suddenly my work is able to send Blue Cross Blue Shield the thing that gave me my benefits the whole time. And that ended up solving the whole issue. So I never actually had to pay any of the bills. I just let them sit for months. I called the hospital to make sure that it was all cleared, and it eventually did get cleared up. But it's so fucking frustrating.

I was making $45,000 a year, and my wife wasn't working, and we had a baby. It's not like, poverty level in Florida, but it's still borderline for a family to live. And then to have the expectation that I suddenly needed an extra $10,000 to pay for something. Like, I'm sure my mom—like I said, she had worked at Darden for a long time—she said she would have paid it, if I had to pay it. But imagine if you didn't have a family member that could cover that. It was sickening to even think about it. And especially the way that no one helped out or anything was really annoying. I hate fucking U.S. healthcare so much. Now my healthcare is really good. I ended up getting a different job, and I moved out to Washington, and now my company covers my premium 100 percent. I have zero deductible. I only pay copays. It's basically like I have universal healthcare now. And it just—the stark difference between the two, and the fact that other people in the United States do not have this great experience that I'm having now and are more likely to be having the former experience that I had—drives me fucking insane.

Sick Note: It makes my head hurt to think about it. Treating a mother and a child that was just born as two separate entities with different insurance plans is so funny. One second, it's a baby that's in a woman, and then she gives birth, and then suddenly it's a new person with a new insurance plan.

Were the bills specifically for the NICU stuff?

Patrick: It was for everything. That's the other thing. The insurance companies don't want to pay out for claims, so everything is itemized. We maybe paid $1,000 or $1,400 total for the hospital stay and the birth. But that was covered over five different bills. We'd get a bill for the wife's hospital stay. And then we got bills for just the anesthesia for the birth. Anesthesia is always covered separately, it's its own thing for some reason. They're also one of the most overpaid people in U.S. healthcare. That was like $300 by itself. Then there was the birth itself, which was covered. Then we had the NICU stay for my daughter, which was the extra amount. That was the biggest amount that we had to pay under either of the bills that we were getting. And then they also have aftercare for the childbirth, what a baby would normally go under for being born and then leaving the hospital.

When the bills started coming in, that's the thing that would also—getting one bill would be annoying, and I would obviously have anxiety about it, and the situation still would have happened. But I was getting two bills the first time I got these extra bills from when the insurance changed. And then I would get one the next week, and then another one the week after, until it covered all of those different things that we were getting billed for. I had this total amount that was $10,000 or $13,000, but it was spread out across these five different bills. The bulk of it was the NICU just because that was so expensive. But they wanted $500 for my wife getting anesthesia, or $300 for the rest of like the childcare stuff. Then it was just all about the difference in the benefits between the silver and the gold plans. The silver plan specialty care only covered 80 percent, but it was after you met your deductible. And of course, the deductible was $10,000 for a family.

Sick Note: Right. The other thing is, the thing that determines what coverage level you have is the amount of premium you pay. Let's say for a gold plan you pay $500, and a silver plan you pay $300. If they changed your plan to silver for December, then technically you should have gotten a refund for the difference.

Patrick: Oh yeah, I didn't mention that! I fucking asked them to refund me, and they wouldn't do it! That's the other thing!

When I was on conference, I was like, 'Okay, you guys can't send Blue Cross Blue Shield, you can't change my benefits in the work.' And they were like, 'No, sir. We cannot do that.' And I'm like, 'Okay, BlueCross BlueShield. It looks like my benefits have changed for 2014. Are you going to refund me the premium that I paid for that month?' And they were like, 'No sir, we cannot do that. I'm sorry, sir.' I'm like, 'What the fuck? That doesn't make any sense! I just paid you for an entire year! You've got to give me the insurance!' That didn't work. It's all illogical. The whole system doesn't make any rational sense.