Question: My independent 24 yr old daughter has Anthem insurance coverage through her father's workplace (Univ. of So Cal). My daughter is low income and it was our plan to enroll the infant in Medi-Cal through CC. We were under the impression that the infant would be covered by my daughter's plan for the first 30 days. Marin General, the hospital where her doctor delivers, has contacted her to let her know that because she is not the policy holder, the infant has no coverage at birth. They let her know that the infant will incur charges from the minute she is delivered and advised her to get coverage. We can't figure out how to sign up just the baby before birth without a social security number.
Answer: You can't get Medi-Cal coverage for the newborn infant until after the child is born, but the baby's coverage will take effect retroactively to the date of birth. That means Medi-Cal will cover all of the newborn's expenses. Once the baby is born, the mother must apply on behalf of the baby using the Covered California online application even though you know the baby will be eligible for Medi-Cal.
Yes, corrected. Dependent children, of a dependent covered under a member’s policy, are not covered under the same health plan. Seems an intended pro-industry oversight and infant no-coverage loophole as established in law.
Anthem not covering claims is a regularity with my clients right now.
Kristine, congrats on being a Grandmother, and the best for your family.
Seems your complaint as filed with the Dept of Insurance has likely made an impact, less likely but possibly so impact of your posted issue here as well, and further shows how Anthem not covering your granddaughter would be outside of the requirement of the law, should Anthem not automatically cover for 30 days a newborn under the newborn’s mother’s health insurance policy. Additionally, Anthem likely does not want any bad press, in particular that as a member your daughter filed issue with the California Dept of Insurance. The CDI acts quickly with such complaint issues.
Max Herr: You say that coverage of the infant was “as expected”. We are confused why the insurance contact at USC, Marin General and Anthem all said, in advance, that no coverage would be be provided to the infant. They were very clear that dependents of dependents have no coverage under their plan, even for 30 days following birth. It’s been such a drag to gather and prepare with information that was not accurate, especially when it comes from the insurer themselves.
Thanks for the update. Glad to know the baby arrived and is doing well. As expected, Anthem should be fully responsible for the baby’s first 30 days of lifetime expenses.
I wanted to update the Anthem coverage situation for the infant born to my 24 year old daughter with insurance through her father’s employer. The baby did incur nursery hospital fees after she was born on April 9. The bill from Alta Bates was a total of $70K, which included $5K of nursery fees for the infant. The bill shows a “contractual adjustment” with Anthem for $50K, and a $20K payment to Alta Bates. My daughter was billed for her hospital co-pay of $250.00. Although I was told prior to the birth by both Anthem and by another hospital that Anthem would not cover care to the infant, at this time it does appear that Anthem has paid those costs.
We will wait to see if Anthem makes any further adjustments and/or bills my daughter for the services for the infant. She has applied for and is now receiving care for the infant paid by Medi-Cal.
Max Herr: Thank you for the link to file for assistance from the Dept. of Insurance. We were able to fill it out and submit it. It may be moot for my daughter as the baby is due any day. Her income qualifies her for Medi-Cal, which we will apply for after the baby is born. Likely they will cover services to the infant starting day of birth. However, I would like clarification from the state that insurers don’t have to provide 30 days of coverage for infants born to insured individuals. Anthem told me they would cover 30 days for an infant born to a policy holder or a spouse of a policy holder, but not an infant born to a covered adult child of the policy holder.
No need to be the one to establish case law precedent on this.
As an alternative, I would recommend filling a “Request for Assistance” consumer complaint with the CA Dept of Insurance ( https://interactive.web.insurance.ca.gov/rfa/faces/request?afrLoop=14837206371791&afrWindowMode=0&adf.ctrl-state=yb2iay8ug4 ), because I believe Anthem’s attempt to avoid coverage for the newborn child during its first 30 days of life is in violation of the Insurance Code section I previously identified.
If nothing else, I would recommend that your daughter fie a complaint (“Request for Assistance”) with the CA Dept of Insurance. If the CDI determines that Anthem is unfairly denying coverage to newborn children in situations as you have described, and determine those acts to be in violation of state law, they will initiate swift action against Anthem.
Because of the nature of unfair acts and its lack of resources, the CDI generally takes a reactive approach — waiting to hear the complaints — rather than a proactive approach to find unfair acts. Unless someone reports what may be an unfair act, CDI may never hear about it, and the problem could persist for some time.
It costs nothing to do that — takes maybe 10 minutes online to file the RFA, and, ultimately, it could be a benefit to many other consumers similarly situated.
Michael and Max: While I was not surprised that the ACA did not require insurers to cover dependents of dependents, I was surprised that an infant born to an insured would not not be covered for some brief period after birth….10 days or 30 days. My daughter’s father despises the legal profession and would never go near a lawsuit or class action involving an insurance company. Though if it were me, and I was the policy holder, I might be interested in helping establish case law on it.
My daughter’s household income will definitely qualify the baby for Medi-Cal, so we will go that route. Surprisingly, the pediatric providers in Marin that accept Medi-Cal and that are taking new patients are ones my daughter would have chosen anyway. That is certainly not the case here in Santa Barbara County.
Thanks again for your replies and help. Kristine
Thanks for clarification regarding newborns of dependents. Anthem’s and Blue Shield’s previous conveyance over the years of automatic newborn coverage for 30 days under the mother’s policy seems has regularly been relayed without such newborn of dependent consideration, but rather with expectation that newborn would be added to the policy.
With regard to applying for and enrolling your grandchild into Medi-Cal before being born, I recommend your daughter create a Covered California account, and list herself as the household member, as pregnant, which will trigger Medi-Cal enrollment. This should eventually lead to a Medi-Cal eligibility determination, where your daughter can decline the coverage, yet her newborn will then be covered under active Medi-Cal.
If you would like assistance, I’d be glad to help.
This is an uncertain issue. Changes to federal health law, courtesy of the PPACA in 2010, which allowed “children” of an insured parent to remain on that parent’s policy until age 26, do not “require” insurers to cover the living dependents of an insured’s child. This doesn’t mean they cannot be covered.
Section 2714, of the PPACA, titled: EXTENSION OF DEPENDENT COVERAGE says this:
(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.
On the other hand, however, California’s Insurance Code, Section 10119, has the following provision:
On and after the operative date of this section [which was January 1, 1997]: (a) No policy of disability insurance which, in addition to covering the insured, also covers members of the insured’s immediate family, may be issued or amended in this state if it contains any disclaimer, waiver, or other limitation of coverage relative to the accident and sickness coverage or insurability of newborn infants of an insured from and after the moment of birth or of any minor child placed with an insured for adoption from and after the moment the child is placed in the physical custody of the insured for adoption. (b) Each such policy of disability insurance shall contain a provision granting immediate accident and sickness coverage to each newborn infant of, and each minor child placed for adoption with, any insured as required by subdivision (a). (c) A policy of disability insurance, self-insured care coverage, employee welfare benefit plan, or nonprofit hospital service plan, shall comply with the standards set forth in Chapter 7 (commencing with Section 3750) of Part 1 of Division 9 of the Family Code and Section 14124.94 of the Welfare and Institutions Code.
I do not believe that the PPACA “pre-empts” California law on this because it does not say that insurers cannot (or shall not) cover dependents of an insured’s child, it simply says they are not required to cover them. The courts generally construe such language to allow states to enact more restrictive legislation. And that’s what California did more than 18 years ago.
In my opinion, I believe Anthem would be in violation of the CIC if it denied coverage during at least the first 30 days of life to a newborn infant. It may deny coverage after that.
I don’t know that this provision under California law has been tested legally against the PPACA yet. But I have attorneys who would certainly be willing to take your case against Anthem, if you chose to press it.
As far as Medi-Cal and CoveredCA is concerned, only pregnant women with incomes less than or equal to 213 percent of the Federal Poverty Line ($33,930 for a household of two, which includes the unborn child) may enroll through CoveredCA.
If your daughter’s income is below that threshold, it is not necessary to add the unborn child to the application. You simply check the box on her portion of the application that asks if she is pregnant. No need for the child’s name or SSN, since it has not yet been born.
If you would like assistance with this, please contact me — there is no cost. You may email me with your contact information, or you can find mine on my website by clicking the link attached to my name here.
Max and Michael: I confirmed with Anthem that the newborn infant is NOT covered by my daughter’s policy for 30 days after birth. The fact that Marin General is calling in advance of the delivery tells me they’ve already encountered this issue of lack of coverage for dependents of young adults still on parent plans. Anthem was very clear and firm, but checked the specific policy for me anyway, and confirmed that their policies for children under 26 do NOT cover dependents of dependents. I had checked with USC personnel when my daughter was only a few months pregnant and they let me know that the ACA did not require coverage for dependents of dependents. However, of the 3 providers (Kaiser, Pacificare and Anthem) for USC employees, Kaiser plans do cover dependents of dependents. However, it would require that both my daughter and her father switch to Kaiser. My daughter lives in Marin where Kaiser is prevalent. Her father, age 63, lives in Santa Barbara where there are no Kaiser facilities. So, that switch was not an option.
I was not able to figure out how to sign up for Medi-Cal via Covered California without a SS# for the unborn infant. My daughter doesn’t need pregnancy services from Medi-Cal and won’t be switching to Medi-Cal for another 18 months (when she turns 26). I think I will wait until the infant is born and has received a SS# before attempting applying for coverage again..
Your daughter’s newborn will, as I understand it, automatically have coverage under your daughter’s Anthem policy for 30 days (or 31 days) from the newborn’s date of birth. There will be no available group employer coverage for the newborn after this initial 30 day period.
She, and/or her father should call Anthem to verify.
Max offers good advice to apply for Medi-Cal now for your granddaughter. Be pro-active to then contact Medi-Cal and request and obtain expedited enrollment for the newborn once born. Expedited enrollment CAN indeed be quick, fast, and expedited, as has been garnered for my clients.
Medi-Cal will be active from the newborn’s date of birth. So will your daughter’s Anthem policy for the newborn, for 30 days under newborn’s mother’s policy. Which insurance is to be primary, or secondary, or whether in conjunction at all (Anthem and/or Medi-Cal) will/may likely depend upon the whether the father’s employer is a large group or small group employer, or some other factors of which, if so, I am not currently familiar.
While the statement that the daughter’s dependent coverage will not cover the baby after it is born is probably accurate, Medi-Cal does enable a pregnant woman whose “household” income is below 266% of FPL to enroll in Medi-Cal and provide coverage for her unborn child. The fetus is considered a “member” of the household, so your “independent” daughter constitutes a “household of two” and 266% FPL would be about $42,373 annually, or about $3531 per month.
If eligible under the income guideline, your daughter can apply for Medi-Cal coverage for her unborn baby now, and need not wait until after it has been born. She can also choose to remain on her father’s health insurance plan or switch to Medi-Cal for her own coverage.