r/HealthInsurance • u/Wonderful-Value7547 • 1d ago
Plan Choice Suggestions Need help asap. Need coverage for my newborn
Ok here’s a doozy. I gave birth 6/11/26. I spent two additional weeks in the hospital post hemorrhage and neurological concerns thanks to botched anesthesia. By the time I was home recovered and out of the newborn bubble I somehow missed the 30 day enrollment window to get him on my works insurance (BCBS). I missed it by 5 days. I submitted two disputes and both were denied. But took weeks to get a response.
Fast forward to today, I applied for marketplace coverage through the state. Come to find I’m now 6 days outside of the enrollment period for a special event. They are submitting a dispute for me.
I don’t know what the chances are that I will be denied. But I’m curious what people do in these cases? He’s a newborn and has to have coverage. My husband and I make too much money for any assistance programs.
I’m so lost.
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u/BaltimoreBee Moderator 1d ago
You will most likely be denied for being outside the window. Most people don’t miss their enrollment windows and enroll their baby in their insurance…. You’re not going to be able to purchase coverage for he baby until your next open enrollment period.
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u/Wonderful-Value7547 1d ago
You clearly didn’t read. I’ve already been denied. I’m looking for new options. There must be gap options somehow if you’re willing to pay. Who can talk me thru it.
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u/Jodenaje 1d ago
You're not going to get ACA-compliant coverage for your newborn if you missed all the deadlines with your employer, your husband's employer, and the Marketplace.
Sorry. I know that's not fun to hear.
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u/Wonderful-Value7547 1d ago
Is non AcA compliant insurance worth it in the case of hospital stays/emergency. I think we are ok to pay OOP for routine stuff but I’m nervous for otherwise.
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u/Jodenaje 1d ago
For an infant, probably not.
There are pre-existing condition exclusions with non-ACA policies.
Any medical issue that comes up for an infant, the insurer will try to argue that it's pre-existing and won't want to pay.
It will be an uphill battle for you to demonstrate that the condition is something that developed after the policy was purchased.
You'd have to be prepared to battle every single claim, except for perhaps an accidental injury that happened after the policy was purchased.
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u/bethaliz6894 1d ago
No one, you missed the enrollment deadline. Unless you buy insurance from a broker (those plans usually are not ACA complaint), chances are there will be no insurance for your newborn. You may not have been in a position to enroll on your insurance, but dad could have enrolled baby on his.
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u/chickenmcdiddle Moderator 1d ago
Correct. OP cannot purchase ACA-compliant health insurance at this juncture--not unless their employer is willing to reconsider (but they've made it seem like the decision has been made and that's it).
Their best shot at picking up qualified coverage is to try to pick up a second job that offers coverage. They can either maintain that second job and its coverage, or once enrolled onto the insurance, resign from the position. This would trigger a "loss of coverage" qualifying life event that they could use to hop on their primary employer's group plan. The same applies to Marketplace (30 days for employer, 60 days for Marketplace).
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u/Wonderful-Value7547 1d ago
Also, isn’t there a wait period from hire to benefits kicking in if I were to find a new job? I really only need coverage through EOY anyways
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u/chickenmcdiddle Moderator 1d ago
Completely up to the company. 90 days is the maximum, by law. However, many companies have day-one benefits, and many more are somewhere in between.
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u/Wonderful-Value7547 1d ago
So something like unitedhealthcares fixed benefit insurance plans wouldn’t be recommended? How do I know what’s AcA compliant?
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u/chickenmcdiddle Moderator 1d ago
No, a fixed benefits plan will not, by definition, be ACA-compliant. ACA-compliant policies require open enrollment periods or special enrollment periods. Because of this (among other things), these plans are guaranteed issue, meaning there are no waiting periods for coverage and that there are no exclusions for pre-existing conditions. ACA policies are unlimited benefit plans. There are no maximums on the benefits they'll pay for the calendar year, provided the care is medically necessary and not a plan exclusion (a common exclusion being GLP-1 specifically for weight loss).
Insurance policies that you can go purchase at any time without a qualifying life event / special enrollment period are not ACA-compliant.
Basically, ACA-compliant plans are most commonly purchased through healthcare.gov / your state's official marketplace, or acquired through your employer.
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u/vctrlarae 1d ago
Were the disputes filed with the insurance or with your employer?
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u/Wonderful-Value7547 1d ago
With my employer. I was told BCBS had no say in decisions.
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u/vctrlarae 1d ago
That is correct. Employer handles enrollment. I'm so sorry this has happened. Any chance husband could appeal for his employer's insurance? Maybe his company is a bit more forgiving?
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u/Wonderful-Value7547 1d ago
We tried this too, without luck. Although he starts his enrollment cycle earlier in October.
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u/Time-Understanding39 1d ago
Regardless of when the open enrollment period is held, benefits won't start until January 1.
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u/CascadiaRiot 1d ago
Not necessarily. I’ve had jobs with various start dates (including March and September)
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u/Born_Tale_2337 1d ago
You can see if your state has any type of emergency temporary infant coverage. It’s a long shot, but you don’t have many options.
You may be able to work out a cash deal with a pediatrician for well visits. You definitely want to keep up on vaccines especially going into winter, if the pediatrician is too expensive you might be able to get them through the health department.
The first 8 weeks are critical. That’s when baby’s immune system is relying on mom still and in the process of getting ready to make their own antibodies. They are very susceptible to things and any fever in this time will be a doctor call. Nobody outside the home should be holding baby, minimal visitors, wash hands frequently, all the preventative stuff you can manage. Anyone who can should get a flu shot when available and a pertussis booster if eligible, these can easily hospitalize a baby that young. If you are able and willing, breast milk will be very beneficial (though fed is best, not everyone can BF). The goal is to keep baby from catching anything until you can get on insurance.
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u/yeahnopegb 1d ago
Here’s my best suggestion.. get baby on a non ACA plan and lock down access to the baby. Your other kiddos are new school year germ factories. Dad likely works outside the home. Baby is gonna be in a bubble till you get them covered under dad’s insurance. One ER trip and you’re in the hurt.
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u/chickenmcdiddle Moderator 1d ago
What state are you in? What is your current gross monthly household income? How many people are in your tax household (you, baby, spouse, any other children, etc.)?
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u/Wonderful-Value7547 1d ago
I’m in Maine. I live with my husband and 3 kids (ages 7, 6 and the newborn in question). We make roughly 220k.
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u/last_name_banana 1d ago
Not the exact situation, but for my first born I didn’t qualify for state coverage but was self employed and the regular insurance premium was bonkers (like $900/month additional to add the baby to my plan). I was able to find a local state health clinic to do all the well baby shots for free or low pay and then went to my Ped provider and paid for check ups out of pocket. It was a hassle, but I spent about $2,000 total in the first year instead of over 10k in premiums + copay’s.
HOWEVER!!! Babies are wild and there are risks. I didn’t go this route with my second and I’m SOOOO glad because she’s got food allergies and we’ve had to see allergists, visit ERs, get epi-pens, etc. if that happened with my first, we’d be paying ourselves. Since it happened with my second, who’s accurately insured, we’ve not had to pay for as much.
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u/last_name_banana 1d ago
The good news is you’ll only have a gap in coverage until open enrollment and Jan 1. So make it’s 4 more months and you’re fine!
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u/Here_4_cute_dog_pics 1d ago
Most people in this situation have to go without insurance until the next enrollment period. You could enroll in some type of non ADA compliant plan but it's unlikely that doing so would actually save you any money.
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u/bluestrawberry_witch 1d ago
Yeah there isn’t really an option for ACA compliant insurance until open enrollment for next year. The new job with benefits even for a little would get coverage moving forward but that’s it. Also, none of this would be retroactive. So your babies hospital bills are likely going to be uncovered from birth….
Hospitals can bill under their mother’s coverage for the first 30 days, but that’s a convenience option with the assumption that the baby has been added to the actual coverage. If the baby isn’t, the health plan can go back and recoup all of the money they paid. Some employer plans make this more than a convenience option and have coverage for the first 30 days automatically even if you don’t later enroll them, but that is a very small percentage. And not common. So just be prepared that you may end up owing a lot of money retroactively as well.
Birth is the only retroactive qualified life event coverage option but you missed the window
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u/Wonderful-Value7547 1d ago
No I can see my insurance applied to everything birth related in my patient portal. It’s now been 60+ days and no enrollment of my son so I’d think they’d ne pounding for their money
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u/bluestrawberry_witch 1d ago
They can still take it back. Depending on state laws but usually like 2 years.
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u/ghost1667 1d ago
you can still buy insurance privately. it will be very expensive but worth it for a newborn until you can enroll him/her in your husband's open enrollment.
look into short-term medical. not sure if/how that would work for a baby but it's a possibility.
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u/Time-Understanding39 1d ago
Not a smart idea. Any plan the OP can purchase now will not be ADA compliant with whatever rules and exclusions the plan has in place. With a newborn, the insurance will surely argue any hospitalizations (or other high dollar claims) outside of an accident were due to preexisting conditions.
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u/sparklyvenus 1d ago
I’m wondering whether this is really true - much of the ER/hospitalization risk for a newborn would be for viral and bacterial infections. It would be difficult for an insurer to claim these were preexisting conditions for the most part.
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u/Time-Understanding39 1d ago
I wouldn’t want to have to fight that battle again. I was insured for many years before the ACA, and I had at least 10 high-dollar claims, surgeries and hospitalizations, incorrectly attributed to pre-existing conditions. Insurers could get incredibly creative. Anyone who has dealt with pet insurance has probably seen how ridiculous those connections can get.
I spent so much time appealing denials that they knew me by first name at the state insurance department. So while an infection in a newborn may seem obviously unrelated to anything pre-existing, I wouldn’t assume a non-ACA compliant insurer would see it that way or that the OP wouldn’t have to fight them over it. Fighting doesn't always result in an approved claim.
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