Newborn Baby Delivery Hospital Stay Dual Membership (DM) Primacy Determination and Coordination of Benefits (COB)

A newborn will be considered to have dual membership (DM) when the newborn’s delivery claim can process under both mom’s and dad’s plans (e.g., mom has HMSA coverage and baby is listed under dad’s HMSA plan etc.)

A newborn can also have DM when the newborn is the subscriber to a plan (from date of birth) and the newborn’s delivery claim can process under the mom’s and/or dad’s plan. In this situation, the newborn’s plan (plan where the newborn is the subscriber) is primary to the mom’s and/or dad’s plan. If the newborn’s delivery claim can process under the mom’s and dad’s plans, refer to the table below to determine primacy between the mom’s and dad’s plans.

In the situations listed below, the mother is NOT a listed dependent under the father’s plan. If the mother does have coverage under two plans, the situation will be indicated below as the parent’s plans being ‘Mother and Mother.’

Coverage of a newborn baby delivery hospital stay depends on whether the newborn’s hospital stay was more than or less than a 2-day stay (for vaginal delivery) or 4-day stay (for cesarean section) – refer to the Maternity – Length of Stay article for additional information on the 2-day and 4-day length of stay.

In adoption situations where the newborn baby is listed under the adopted parent’s HMSA plan from the baby’s date of birth (DOB), coordination of benefits (COB) with the natural mother’s HMSA plan will also occur as indicated in the table below.

Example: Adopted mother listed newborn baby from the baby’s DOB, the natural baby’s mother did NOT list the baby on her plan, and the length of stay was less than 2 or 4 days. The newborn’s claims will process under the adopted mother’s HMSA plan and COB under the natural mother’s HMSA plan (this situation is identical to Situation #3 below where the adopted mother = father and the natural mother = mother)

*Birthday Rule: The parent who has the earlier birth month and day in the calendar year is primary for the newborn. If both parents have the same birth month and day, then the plan that has earlier effective date (for the subscriber of the plan) is primary.

In situations where the claim is processed under the mother’s plan before the newborn was subsequently added as a listed dependent under the father’s plan, the primary plan will be the father’s plan (the plan where the newborn is the listed dependent). The claim under the mother’s plan will be reprocessed and coordinate as the 2° plan for the first 2 or 4 days.

In situations where the claim is processed under the mother’s plan before the newborn was subsequently added as a listed dependent under the mother’s and father’s plan, and it is determined by the birthday rule that the primary plan will be the father’s plan, the claim under the mother’s plan will be reprocessed and coordinate as the 2° plan.

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