Tricare (I know, I know...lol)

[Plummeting]

Okay, I've read the big Tricare thread from a couple years ago...several times. lol I just have a couple of questions still, for clarity's sake.

First, our base (Millington, TN) has a women's clinic, but there's no hospital and no babies are delivered on base, so that means I might be able to remain on Prime, right?

Second, there is a local CNM who does homebirths. She's licensed, it's legal in the state - all that jazz. She is not an in network provider, however. So would that mean that I couldn't stay on Prime after all? lol

And whether I have to do Prime or Standard, if she doesn't want to be in network or a participating provider does that mean that I would pay her, then be reimbursed by Tricare up to the allowable charge?

Does anyone have a link to what the allowable charge is at this point? lol

Thanks so much!

[nashvillemidwife]

I'm very interested in knowing how paying her and being reimbursed by Tricare would work in this situation. There is a federal law that providers cannot charge you more than 15% above what Tricare covers. Unfortunately, for this reason alone my practice cannot accept Tricare payments because that amount is simply too low for us to make it work.

[Plummeting]

Well, lots of women here have made it work somehow or another. I've seen several mentions of what Tricare covered vs. what the women were left paying and generally speaking, they paid a lot more than 15% over what Tricare did. What I read was that the allowable charge a few years ago was $1600. I know that's not enough when you add 15% and I'm not sure what the current TAC is.

The amounts I've seen people who birthed with Tricare ended up being charged ranged from $2500 to $3500 or thereabouts. Maybe they broke the law? I have no idea. I just know women get Tricare homebirths all the time and I'm trying to figure out how to do it, one way or another. It might not be possible, but it might. Thanks for explaining that to me, though. I hadn't even considered anything like that rule, although I may have once known about it, due to having gone out of network for my daughter before.

[nashvillemidwife]

I've read all about it here and I'm guessing most people don't know about the legal restriction. I didn't until just recently. There are also midwives who charge less than we do, and also midwives who are able to accept the cut. Unfortunately we just can't.

[railyuh]

You should be able to add any CNM to the in network provider's list by calling tricare.

If she doesn't want to be a network provider, you can stay on Prime and us the Point of Service option. There is a deductible (I think $200-300 last I checked) and then they cover half of every bill IIRC. I believe you pay and then Tricare cuts a check to you for their portion. With PoS you are obligated to pay the midwifes full fee and not bound by the 15% thing since she is not a network provider.

My midwife is a CPM and RN and she is just billing to Tricare to see what happens. I'm not sure how they'll cover it or how much of it they will cover (if any), but I definitely plan to make sure my midwife gets her full fee even if I have to "gift" the rest of it to her beyond what Tricare will pay. I am hoping since she is an RN they will cover her since I know they generally don't cover CPMs.

[luv-my-boys]

I have no personal experience with homebirths but I thought I'd chime in with my experience w/tricare to get get stuff covered. First off if there is a tricare clinic on base I would go there first, I have found that the 1-800# to be even more confusing as half the time they transfer you to several depts. all of which tell you very different if not conflicting things. Its better to go face to face and have a live *person* to help you.

You might be able to stay on prime if you are not able to deliver at the clinic and you must seek *civilian* care. If there is a MTF than you might be assigned to go there.

Tricare has a little rule that patients must be able to receive appropriate care within 50 miles of their home whether that be MTF or civilian. In our case we did not have any in network providers within 50 so we were allowed to pick a non network provider and NOT pay POS. POS typically is more expensive on your part since you have the cost share. We are reinbursed the tricare allowable fee ( the amt they would pay a in network provider, we pay any overage). In our case we pay out of pocket and then submit the claim to tricare. But that is because our provider does not bill any insurance.

If your midwife is willing to bill tricare than the *check* would be cut to her. If your CNM is willing to become an in network provider that helps a lot. However, in my experience its not too beneficial for the provider to do so. First they are under contract so are only reinbursed X amt. Also they do have paperwork to do for them,creditials,licensing...and if your midwife is not up to that that leaves you filing the claim.

We do this A LOT as most practioners in our area either do not accept any insurance (cash only) or wont accept tricare. We first get approval for out of network provider-provide proof the nearest provider is over 50 miles. and submit claim once we get billed and make up the difference.

[FreshDidysOnLine]

Here's my 2 cents - pregnant and seeing a CPM (not CNM) in a legal state. She is not covered under prime because I am close enough to a military base that has an L&D.

I switched to standard because she said she had much better luck getting tricare to reimburse and pay for labs etc. In my MW's experience, Tricare has reimbursed UP to $2400 (almost 50% of her cost), but that is not guaranteed. I've been told they don't actually guarantee any reimbursement, so we know that we can owe up to her full fee of $5000.

I don't know all the ins and outs of it, but that's what we are doing. Good luck!

[nashvillemidwife]

Originally Posted by railyuh

If she doesn't want to be a network provider, you can stay on Prime and us the Point of Service option. There is a deductible (I think $200-300 last I checked) and then they cover half of every bill IIRC. I believe you pay and then Tricare cuts a check to you for their portion. With PoS you are obligated to pay the midwifes full fee and not bound by the 15% thing since she is not a network provider..

It appears your information is incorrect:
http://www.tricare.mil/Factsheets/vi...eet.cfm?id=183

1. They cover half of Tricare's allowable charge, not half of every bill.
2. The 15% does apply.

The 15% thing is specifically in reference to out-of-network providers. It's federal law designed to protect military families from being fleeced if they live in an area where services are hard to come by. It's a good idea in theory because fees for medical services do tend to be inflated (though don't all families deserve such protection?), but midwife's fees for home births really don't compare so you actually end up screwed in these situations.

[Plummeting]

Originally Posted by nashvillemidwife

It appears your information is incorrect:
http://www.tricare.mil/Factsheets/vi...eet.cfm?id=183

1. They cover half of Tricare's allowable charge, not half of every bill.
2. The 15% does apply.

The 15% thing is specifically in reference to out-of-network providers. It's federal law designed to protect military families from being fleeced if they live in an area where services are hard to come by. It's a good idea in theory because fees for medical services do tend to be inflated (though don't all families deserve such protection?), but midwife's fees for home births really don't compare so you actually end up screwed in these situations.

Yeah, that's what I gathered after I looked into it. There are providers near me anyway. Tons and tons and tons of OB's, whose websites say things like this:

Although we are advocates of natural labor and will support you if this is your plan, we are not proponents of the “Bradley Method.” We believe very strongly in doing what is in the best interest of both the mother and baby, and therefore cannot adhere to the unusual expectations set forth by Bradley courses you may have attended.

Because, yes, expecting to actually have a natural childbirth is an "unusual expectation". :

So there are lots of providers...10 or so in that one practice alone. They just all seem to be a bunch of jerks who don't actually want women who desire natural births to show up at their practices.