You'll find hundreds of files on cleft lip, cleft palate here on widesmiles.org.

This one is about: When Both Parents have Insurance Coverage


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When Both Parents Have Insurance Coverage:

The question came to Cleft-Talk ----

We both have pretty good health benefit plans at our jobs. Hers is an HMO and mine is not. What can we expect from these insurance cos. when it comes time for all these surgeries? I am assuming that we will have to fight, but just how much? Any words of advice?

And Beth Kaeser answered ----

You may or may not have to fight, so you can put your gloves away, for now anyway!!!! :)))) Who is the primary insurance for the baby??? That would be probably whoever's birthday, that is first in the calendar year. (ie, My b-day is July and my husbands is in Sept, so I would have the primary insurance on our son, and Rob's would be secondary). It makes a big difference sometimes. With 2 insurances, most likely, almost all of the costs will be paid for. Whatever the primary insurance does not cover, the secondary probably would. Does that make sense???

The problem with insurances usually arise when the kids have surgery when they are older. The initial repairs are usually not a problem, because they are reconstructive and there is little questioning of the need for the repair. Some parents have trouble with later surgeries because the insurance company would love to call them cosmetic (which is wrong), instead of reconstructive  and therefore a fight happens (bring out the gloves then!!!).

So, in your case, the surgeries now, should be covered by a combo of both of your insurances. Just make sure you have the primary and secondary things figured out, which you probably already do...make sure to use both insurances to their fullest!!! If the HMO is primary, make sure to get any referrals you need and try to stay in their network so you do not get penalized. Also make sure you get the surgery/hospital stay pre-certified or whatever the rules are. (many times the PS takes care of this, but I always used to double-check, just to be safe.)

We have one insurance, so anything our insurance does not cover will be our own expenses. That is pretty scary, but is how it goes since I decided to be a stay-at-home mom. We were very lucky with the state of Ohio, they picked up everything that our insurance didn't cover under the State's Bureau of Children's with Medical Handicaps (BCMH), which Paul qualified for. Now we are in CA, and we are over the salary limit for the CA system...oh well...

If anyone needs insurance info, or if you are in Ohio and need BCMH help, I can give it!!!! :-)

Note: For information on BCMH, see cleft links file 783.


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