My ODS insurance and Midwives... interpret??

[misskira]

I emailed my ODS insurance company to ask if my plans covers "out of hospital birth with a licensed, non nurse, midwife?"

Here is their answer. Anyone care to put it into English for me? I think I understand what it means but would like another opinion. I chose to email first rather than calling so I had written documentation of their answer.


Dear Ms. _____,

Thank you for the email. The plan does cover the services of licensed and certified nurse midwives or certified nurse practitioner midwives. At this time ODS does not have any licensed and certified nurse midwives or certified nurse practitioner midwives contracted. Your plan does allow out of network services if you do choose to seek services. The only ODS contracted birthing centers at this time are hospital based. The Birthing Center must be staffed by licensed Nurse Practitioners and/or physicians (MD's/DO's) to be eligible for contracting and claims reimbursement. There are no independent birthing centers contracted.

The purpose of this criteria is to ensure the medical safety of our members during delivery should anything go wrong. By being hospital based and at a minimum receiving care from Nurse Practitioners our members will have access to high level expertise and emergency care at all times.

If you should have any questions or concerns regarding this response, or if you have any additional questions, please do not hesitate to contact us.
Thank you,
Heather

[WifeofAnt]

I think what they're saying is they cover nurse midwives only. That's how mine is but the only midwives in the area aren't nurses. If I want to use one of the midwives around here its completely out of pocket.

[Lady Lilya]

What state are you in?

They are saying they cover CNMs, not CPMs.

They are also saying that they have no home birth CNMs in network. But some birth centers.

I ask about what state you are in because in NY I remember that they had to pay my home birth CNM as if she were in network because there were no options provided in network. That applies to other specialists too. If there isn't one in network, they have to pay your choice as if he/she is in network.

[misskira]

I'm in Oregon. And I KNOW that there is at least one local free standing birth center with a CNM on staff. I'm thinking my next route will be to call them and start fighting for in network coverage of someone since they don't offer any in network coverage. Also, I found this on their website:

Are midwives and birthing centers covered?

Yes. Effective June 1, 2010, ODS began covering certified nurse midwives and birthing centers.


Which to me says their kind of pretending to offer something that really isn't a choice.

[Lady Lilya]

Well, the letter didn't exactly say that there are no birth centers with CNMs. Just that the birth centers in their network also have nurse practitioners or physicians. I'm thinking they could have both, with the more medicalized person counting as backup.

[kalamos23]

Where are you in Oregon? If you are near Portland, you have a better chance of getting a free standing birth center covered. I'm in Oregon as well, and the only one that covers home births in Oregon seems to be Blue Cross Blue Shield (which totally stinks because we HAD BCBS last year and they switched us to Providence this year) Most of the others (from the many midwives I've talked to) will only cover home births WITH a CNM, and unfortunately there are no CNMs that I am aware of in Oregon not in Portland (haven't looked there) that will do home births.

However, they did just reopen a new birth center in Eugene/Springfield that is supposed to be really nice. I do think it might be part of the hospital but not physically - it has its own location. I can give you more info if you want, from everything that I have read, this WILL be covered by insurance since it has CNMs.

[misskira]

Originally Posted by kalamos23

Where are you in Oregon? If you are near Portland, you have a better chance of getting a free standing birth center covered. I'm in Oregon as well, and the only one that covers home births in Oregon seems to be Blue Cross Blue Shield (which totally stinks because we HAD BCBS last year and they switched us to Providence this year) Most of the others (from the many midwives I've talked to) will only cover home births WITH a CNM, and unfortunately there are no CNMs that I am aware of in Oregon not in Portland (haven't looked there) that will do home births.

However, they did just reopen a new birth center in Eugene/Springfield that is supposed to be really nice. I do think it might be part of the hospital but not physically - it has its own location. I can give you more info if you want, from everything that I have read, this WILL be covered by insurance since it has CNMs.

I'm currently with the CNMS at that birth center. I loved the care I got with my first pregnancy, but they got worried about size, sent me for an ultrasound, and then refused me to deliver at the birth center because they were afraid he was too big. So the OB recommended induction at the hospital, which ended up in a csection (and a 8 pound 14 ounce baby). Now that I've had a csection, I can't try for a vbac at the birth center. But they will still attend a hospital birth for me. I'm really trying to avoid another csection so am looking into my options. If I can get my insurance to accept the midwife towards my maximum out of pocket expenses that would be ideal, just in case I do need a transfer.

In Eugene I know of Sacred Waters free standing birth center. They have a CNM on staff. I have an appointment to go in tomorrow. I can pay $15 to have their people work with the insurance company to determine coverage for me. I would be ok with a birth center birth, but am really trying to avoid the same situation I was in the first time.

[kalamos23]

Yikes, that is a little scary - I actually have an appt with them next week (not SW, the Riverbend ones). DD was 8lb 7oz a week early, so it is really conceivable that I would have a bigger baby next time... that being said, if Sacred Waters doesn't work out (and I tried them out with my pregnancy with DD) with insurance, you could try the whole come into the hospital in transition/pushing...

I had a long labor with DD (48 hours) but didn't go into the hospital until I was in transition - it cut down on the amount of interventions and the clock being started on me.

It sounds like your best option would be Sacred Waters though - I really hope that insurance will cover it! I'm guessing that they will cover it at the out of network price.

[misskira]

Originally Posted by kalamos23

Yikes, that is a little scary - I actually have an appt with them next week (not SW, the Riverbend ones). DD was 8lb 7oz a week early, so it is really conceivable that I would have a bigger baby next time... that being said, if Sacred Waters doesn't work out (and I tried them out with my pregnancy with DD) with insurance, you could try the whole come into the hospital in transition/pushing...

I had a long labor with DD (48 hours) but didn't go into the hospital until I was in transition - it cut down on the amount of interventions and the clock being started on me.

It sounds like your best option would be Sacred Waters though - I really hope that insurance will cover it! I'm guessing that they will cover it at the out of network price.

Well. I didn't mean to worry you. Because I would recommend them to anyone. I loved 4/5 of the midwives, and the 5th I didn't really get to know. Emily was wonderful support while we were trying to make the decision on whether to go for the csection when I didn't get into labor. She was kind and compassionate and supportive. She went into the csection and still delivered Logan out of my tummy. I saw her last week for my first appointment and she was really optimistic and encouraging of me going for vbac. I know they have to be careful, and I respect that. I definitely feel comfortable with them as my care providers again, but really want to avoid the csection. So my fear is really of the hospital itself and consulting ob's putting the pressure on. Also that they will only let me go to 41ish weeks.

And I'm not really set on an out of hospital birth. I'm not fully comfortable with the uterine rupture risk yet (still need to read more) and for some reason I'm terrified of placental abruption. I went to Sacred Waters today and Anita was awesome and supportive. We have a lot of decision making coming our way.

My other consideration is doing the hospital birth but hiring a doula. And then being really careful to eat a high protein and veggie diet and low carbs, as well as exercising to try to grow a smaller baby.

Definitely go to the CNM birth center with an open mind. Everyone there is so warm and friendly.

[kalamos23]

I'm not too worried about it, they will be heads and tails better than my current OB - let's just say I've gotten really great at advocating for myself.

It's too bad they won't let you vbac - I really liked Anita as well, I can't remember why I didn't end up going with them, it was probably insurance related. I don't think they had a CNM when I was pregnant with DD (or I didn't know about it) so it would have had to have been totally OOP for us.

Do they really consider not quite 9 lbs a big baby though? The reason I ask is because that is a big red flag to me. Both DH and I are tall people and we both have siblings that were over 9 lb babies in the family (DH probably would have been, he was 8.5 3 weeks early, his brother was almost 10, my brother was 10.12, 2 sisters over 9 lbs). All were birthed vaginally just fine - so to me, 8-9 lbs sounds like an average baby, not a big baby. I do appreciate you mentioning this, I'm making a list of questions to interview the CNMs, so I will definitely be asking about this.

[misskira]

Originally Posted by kalamos23

I'm not too worried about it, they will be heads and tails better than my current OB - let's just say I've gotten really great at advocating for myself.

It's too bad they won't let you vbac - I really liked Anita as well, I can't remember why I didn't end up going with them, it was probably insurance related. I don't think they had a CNM when I was pregnant with DD (or I didn't know about it) so it would have had to have been totally OOP for us.

Do they really consider not quite 9 lbs a big baby though? The reason I ask is because that is a big red flag to me. Both DH and I are tall people and we both have siblings that were over 9 lb babies in the family (DH probably would have been, he was 8.5 3 weeks early, his brother was almost 10, my brother was 10.12, 2 sisters over 9 lbs). All were birthed vaginally just fine - so to me, 8-9 lbs sounds like an average baby, not a big baby. I do appreciate you mentioning this, I'm making a list of questions to interview the CNMs, so I will definitely be asking about this.

The issue is I was measuring large and Logan was really high and not tucked in. So I also looked huge. When feeling him they thought he was going to be big so at 37 weeks they sent me in for an ultrasound. They guessed him at just over 10 pounds, and at my follow up appointment the next week they figured he would be closer to 11 pounds. They decided he would be too big to try to birth at the birth center and referred me to an OB for consult. The OB (I really liked him, Dr. QB) gave me 3 options- immediate csection, immediate induction or wait and see. They were thinking that his stomach measured bigger than his head, and were really concerned with shoulder distocia. The OB wasn't thrilled with the wait and see option, since he hadn't descended yet and I was showing no signs of going into labor soon. They didn't want him to get much bigger. So we went ahead with induction with cervadil, which didn't work. They broke my water in the morning, and was willing to try pitocin in the evening. But they only wanted me to go 24 hours after my water was broke so there was only 8 hours left at that point. Also, they were still very concerned with a big baby and the OB on call came in to talk about the risks including baby getting stuck, brain damage or death. Which of course was scary so we went with the csection. I think with the information we had at the time it was a reasonable choice, but after they weighed him I was a little bummed.

They did make a big deal about how it was my first, and that was part of the concern. If I had already had a baby before, they wouldn't be as worried about the size. So there's that. During the pregnancy they were very positive and kept pointing out the large babies on the birth board. Everyone I know and strangers were making comments on how big I was and how they were sure Logan would be huge. I did a good job of keeping positive, until that appointment when the midwife first told me that my baby was huge at 36 weeks. I cried, but got positive again through the week. Then at my 37 week appointment they sent me for the ultrasound and it went downhill from there. I did feel supported by the midwives through the whole process, and would 100% be set on using them again IF they would let me vbac in the birth center.

[EowynRoh]

I know this is a old post, but I have questions about my ODS coverage in relation to the resourses offered here in the Portland metro area.When I contacted a midwife that I was referred to, I was told that ODS coveres home birth out of network. What does that mean?? Actually, home birth is not what I want. I am looking for a birth center that has a water birth facility. I'm hoping for a birth center that has a hotel-like atmosphere. The reason I don't want a home birth is because my dogs are extremely clingy, and would cause me stress. I could try to arrange for a friend to take them for a while, but I want to be realistic about the situation. They are 2 big dogs. This is my first baby. Orchestrating everything at the last minute (should timing be a surprise) would be a huge cause of anxiety.

Are there any water birthing centers that ODS will cover?