Originally Posted by AlexisT
mamakaryn: you need to be able to demonstrate that there are no providers in-network, within a reasonable distance, who provide the (covered) benefit. Then they may agree to pay an out of network provider at the in network rate (so, 100% versus 70% or in the case of an HMO with no out of network benefits, 0%). The catch is that these percentages are of the "usual, customary, and reasonable charge", which may be less than your midwife's fee. Network providers are required to accept UCR as payment in full but non network providers are not, so you could still be left with a balance.
if there are midwives in network who do home birth, they probably won't make an exception for another provider.
I spoke with the receptionist at the midwifery practice that has 2 midwives in network. She told me that everything EXCEPT the birth will be covered, because the midwives are only covered at births they do at the hospital (OHSU). She said cigna is not a fan of home births. Still, that's better than not covering anything at all. Unfortunately, though, we do have the HMO so these ladies are my only (covered) option, so I hope I feel comfortable with them. The only other thing I can do is call every single listed CNM in the local network and ask them if they would consider attending my home birth.
So, since there are at least 2 covered midwives, I wouldn't be able to get an out of network exception. Darn. I hope I like these women!