[Jack.Kerr]

Score one for the newborns.

Crowley newborn with heart defect is denied insurance coverage
Posted Thursday, Mar. 25, 2010
BY JAN JARVIS
jjarvis@star-telegram.com

At birth, Houston Tracy let out a single loud cry before his father cut the cord and handed him to a nurse.

Instantly, Doug Tracy knew something was wrong with his son.

"He wasn't turning pink fast enough," Tracy said. "When they listened to his chest, they realized he had an issue."

That turned out to be d-transposition of the great arteries, a defect in which the two major vessels that carry blood away from the heart are reversed. The condition causes babies to turn blue.

Surgery would correct it, but within days of Houston's birth March 15, Tracy learned that his application for health insurance to cover his son had been denied. The reason: a pre-existing condition.

"How can he have a pre-existing condition if the baby didn't exist until now?" Tracy asked.

New federal legislation that will prevent insurance companies from denying children coverage based on a pre-existing condition comes too late for the Tracys. The legislation, passed by Congress and signed by President Barack Obama this week, won't go into effect until September.

But Houston, who is hospitalized at Cook Children's Medical Center in Fort Worth, needs coverage now.

Without surgery, babies with this condition often die soon after birth, although some may live as long as a year, said Dr. Steve Muyskens, a pediatric cardiologist.

"In his case, we had to intervene in the first days of life," Muyskens said.

The defect

With this condition, oxygen-rich blood goes back to the lungs and oxygen-poor blood goes back to the body, depriving it of oxygen and damaging the heart muscle. Surgery to move the arteries to their normal position is usually done within three to five days of birth. It basically involves swapping the misplaced arteries.

"It sounds simple, but it's complex because you have to move tiny coronary arteries that in a baby are 1 to 2 millimeters," Muyskens said.

Doug and Kim Tracy, who live in Crowley and are self-employed, carry health insurance on their other two children. They said they cannot afford insurance for themselves.

They paid out of pocket for Kim Tracy's neonatal care and the baby's delivery. Doug Tracy said they were told that they could apply for insurance for Houston within 30 days of his birth.

A spokeswoman for Blue Cross Blue Shield of Texas declined to comment but issued a statement saying, "Our policy is that if a family has existing coverage with us, a baby can be added to the contract within 31 days without the need for underwriting to assess the baby's eligibility."

But that's only if the parents have coverage, said the spokeswoman, Margaret Jarvis. Read that with the emphasis on parents.

Lawmaker tries to help

After being contacted by the Tracy family, state Rep. Chris Turner, D-Arlington, said he asked the Texas Department of Insurance if there are provisions that can be used to help the family. He said he has not received a complete answer.

Virtually everyone can agree that no one should be denied health coverage because of pre-existing conditions, Turner said.

Tracy said he was appealing the insurance company's decision.

A five-hour surgery to correct the defect was performed Friday, and Houston is doing well. He is being fed through a tube and must learn to swallow. But he should be able to go home within a couple of weeks, Tracy said.

"He's such a fighter, and the doctors say he's got a lot of spunk," Tracy said. "The nurses nicknamed him 'Little Rocky.'"

March 30, 2010
Health Insurers to Comply With New Rules for Children
By ROBERT PEAR
WASHINGTON — Under pressure from the White House, health insurance companies said Tuesday that they would comply with rules to be issued soon by the Obama administration requiring them to cover children with pre-existing medical problems.

“Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. Accordingly, she said, “we await and will fully comply with” the rules.

Ms. Ignagni made the commitment in a letter to Kathleen Sebelius, the secretary of health and human services, who had said she feared that some insurers might exploit a possible ambiguity in the new health care law to deny coverage to some sick children.

The White House immediately claimed victory.

In a Twitter message, Robert Gibbs, the White House press secretary, scored the tug of war as “Kids 1, insurance 0.”

Major provisions of the law take effect in 2014. Some, including a ban on “pre-existing condition exclusions” for children under 19, take effect in September. The law does not explicitly say that insurers must sell insurance to families with such children this year, but Democratic Congressional leaders and White House officials said that was their intent.

To eliminate any ambiguity, Ms. Sebelius said, she will issue rules defining the scope of the new law.

Under these rules, Ms. Sebelius said, “children with pre-existing conditions may not be denied access to their parents’ health insurance plan,” and “insurance companies will no longer be allowed to insure a child but exclude treatments for that child’s pre-existing condition.”

In response to a question, Nick Papas, a spokesman for the Department of Health and Human Services, said the rules would require insurers to offer coverage to children with pre-existing conditions, including those who have never had health insurance.

Ms. Sebelius said she was pleased that “insurance companies plan to do the right thing.”

It was not immediately clear whether the rules would allow insurers to charge higher premiums to families with children with pre-existing conditions. Administration officials said they would be monitoring any rate increases.

Some Democrats in Congress want Mr. Obama to take a tough line. If insurers could raise premiums without limits, they would, in effect, be denying coverage, Democrats say.

Some insurers said they were unclear about the language of the law, based on differing accounts, and looked forward to detailed guidance from the government.

“There has been some confusion regarding the elimination of pre-existing condition evaluation for children in the health care bill,” said Kristin E. Binns, a spokeswoman for WellPoint, one of the largest insurers. She said the company would “follow the law on this and all matters.”

Insurers said they would accept the administration’s reading of the law, even if they did not fully agree with it, because they wanted to avoid a showdown over the politically explosive issue of health insurance for sick children.

Several lawyers said Congress could easily clear up any confusion by revising the law. “The real solution here is a legislative fix so all players in the industry can act according to a clear set of rules,” said William G. Schiffbauer, a Washington lawyer whose clients include employers and insurance companies.

Representative Allyson Y. Schwartz, Democrat of Pennsylvania, who helped write a similar provision in an earlier version of the legislation, said the new law “requires that all insurers issue insurance to children regardless of health status, and cover all of their ailments,” starting in September.

Jeff Smokler, a spokesman for the Blue Cross and Blue Shield Association, said its member companies were “fully committed to complying with the new law” and accepted the principles set forth by Ms. Sebelius.

Gail K. Boudreaux, executive vice president of the UnitedHealth Group, said she supported the administration’s effort to clarify the law “to ensure that no child will be denied access to health insurance because of a pre-existing condition.”

“We expect that the new regulations will eliminate any uncertainty about the law’s intent,” Ms. Boudreaux said.