The Pennsylvania Act 81 (Act 81)* states that any health insurance plan written in the state of Pennsylvania must cover the newborn child of a covered parent for up to 31 days after the date of birth, even if that child is not added as a dependent on the policy.
If both parents have their own plans, then both policies must provide newborn coverage for that first 31 days. Also, if the mother or father is an eligible dependent on any of their parents' plans, the grandparents' plans must provide newborn coverage for that first 31 days.
Note: Some group contracts may classify grandchildren as eligible dependents.
When a patient is admitted, please obtain insurance information for both parents and submit the baby claims to the coverage of the parent with the earliest birthdate (month and day).
A common situation you may encounter
Jim and Elizabeth had a baby. Elizabeth has her own health insurance plan and Jim is a dependent on his mother's plan. Elizabeth's plan must provide newborn coverage for the first 31 days. Jim's mother's plan must also provide newborn coverage for the first 31 days.
Coordination of benefits (COB) would apply in this situation, as more than one insurance plan is responsible for providing newborn coverage. COB applies in these types of cases to ensure that services are paid by the proper plan and that claims payments are not delayed, as well as to reduce claim adjustments due to not sending bills to the correct carrier for primary coverage.
*Some self-funded group health plans may opt out of Act 81.
Ask expectant parents about their coverage
As a provider, make sure to ask expectant parents if they are covered under more than one health insurance plan, or are dependents on anyone's plan. If so, consult the Billing section of the
Provider Manual for Participating Professional Providers for details on COB policies and procedures.
Just as you do everything in your power to deliver the best care for patients, we do everything in ours to ensure practices and hospitals are accurately reimbursed for that care. We appreciate your cooperation in this matter.
If you have any questions regarding this mandate, please email us at
pnsproviderrequests@ibx.com.