Petition insurance company to cover homebirth before or after birth?

[Ava'sMommy]

We are planning a homebirth for our third baby due in September.  We have Priority Health (Michigan) and my midwife has already mentioned that she has not had any luck with coverage with them.  She usually bills after birth, but I am wondering if it is a better idea to get a head start.  My husband's employer has fairly close ties with Priority Health (they each sit on each others Board of Directors) so I think that if I start early and coordinate with his employer's insurance liason at work, I could have a good chance of obtaining coverage. 

Any experience on what is the best way to go?  Should I start with a letter to our insurance company, a phone call, contact with the employee insurance liason??  I am currently 19 weeks and have had 4 appointments with our midwife so far.  Thanks much!!

[MonkeysInk]

Start now!  If you wait until after the birth, you'll be out of luck, as you need to request preauthorization for charges that you'd like them to pay that aren't normally covered.

(disclosure: I've worked in HR/benefits for the past ten years, and successfully petitioned my insurance to pay for my homebirth)

Call the customer service number on the back of your card and get all of the details on what specifically is covered for both in and out of network midwifery.  Let them know that you've been seeing a provider and you'd like to request that she be covered at the in-network rate in order to ensure continuity of care.  You'll probably get transferred to someone in care coordination, or the like, and have to tell your story again.  If you used this midwife previously, let them know - continuity of care is one thing that could potentially sway the decision.

If you get declined, find out what the appeal procedures are.  Look in your plan's Summary Plan Description (and if you don't have one, get a copy ASAP - your plan is legally required to provide you with a copy of it).  There will be information on how to file an appeal.  Keep it very fact-based - continuity of care, previous experience with midwives/homebirth, less expensive than the average hospital birth in your area (find those numbers online).  

What ended up being the least expensive route for us was to pay our midwife her cash rate, to guarantee that we got the lowest price even if our insurance ended up not paying at the in-network rate.  Since we knew that they would cover her at the out-of-network rate, we knew that we would get at least a portion of her fee reimbursed, and we wanted our costs to be as low as possible.  It works out great for us - the 80% that insurance reimburses is ~110% of her cash rate, so we end up with no cost and she ends up getting paid more than the cash price.  Totally legal, totally ethical and benefits us, the midwife and the insurance company all at the same time.  Us, because it's free; the midwife because she gets a few hundred extra dollars; and the insurance company because they'll spending ~10k less than on a hospital birth.

I'm not on here much, so PM me if there's anything else that I can answer for you about insurance/benefits.

[Jaimee]

I just wanted to say that we did manage to get our homebirth covered at 80% as an "out of network provider."  We had to fight b/c they said we needed pre-authorization for "home health."  We did not assume homebirth was under "home health" rather under "maternity."  It sounded like they wouldn't have had any issue covering it under home health, so pre-authorization would be the way to go in that case.  However, we did make it work after the fact by appealing their decision with a nice letter explaining all the money we had saved them.  A third party (the state of Maryland) made the final decision and mandated the insurance company to cover it!

[Neuromancer]

Originally Posted by Ava'sMommy 

We are planning a homebirth for our third baby due in September.  We have Priority Health (Michigan) and my midwife has already mentioned that she has not had any luck with coverage with them.  She usually bills after birth, but I am wondering if it is a better idea to get a head start.  My husband's employer has fairly close ties with Priority Health (they each sit on each others Board of Directors) so I think that if I start early and coordinate with his employer's insurance liason at work, I could have a good chance of obtaining coverage. 

Any experience on what is the best way to go?  Should I start with a letter to our insurance company, a phone call, contact with the employee insurance liason??  I am currently 19 weeks and have had 4 appointments with our midwife so far.  Thanks much!!

Yes! to everything MonkeysInk wrote.  That's great information.

I'd also say -- start as early as possible. Getting it worked out takes months, in my experience.  I went through this recently (still waiting to hear from my midwife's billing person how it's all worked out), but what I did was:

1. Called the insurance company to talk about homebirth coverage.  Got the run-around.  They claimed I'd need to be having a midwife birth in an "approved facility" even though home birth wasn't explicitly mentioned in my company's plan.

1b. Also, my midwife's billing person contacted the insurance company several times to ask different people questions about preauthorization, etc.  She was feeling good about my prospects and thought they'd probably cover most of the costs after the fact (at least as "out of network") even if they wouldn't admit that beforehand.  She did say it can be good to call several times, so that you talk to different people.  Take notes and write down the names of people you talk to and what they say. 

2. Emailed my HR person, who contacted the insurance company and got the run-around.  She was told she couldn't approve me on an individual basis, which was what I was hoping they'd do.

3. My HR person emailed the benefits person in the company that OWNS my company, and she talked to our insurance rep, who said some sort of misleading things about home birth not "typically" being covered for their clients.  Basically, the insurance company wouldn't say whether they'd cover my birth or not.  They were hedging their bets, I guess.

4. The company that owns my company actually re-wrote my company's insurance plan to add the phrase "including home births" to its maternity coverage in the Summary Plan Description.  But I was lucky in that I got pregnant in 2010 and they were able to make this change during their normal yearly update period so that it was in place by the time the 2011 plan coverage details were issued (I gave birth last month). 

I did talk at length to the staff in my midwife's office to get lots of helpful info on state law and insurance coverage so that I had "boilerplate" phrases and points to make when talking to everyone involved.  I took a lot of notes!  And I contacted other midwives in the area to see what their experience with my insurance company had been.  Turned out some people had been paid with no problem, which gave me courage even before my plan was updated.
 

I know your situation and the timing is different, but I hope this helps somehow.  Good luck!

[Ava'sMommy]

Thanks to each of you ladies for the helpful replies.  I spent the weekend doing research and reviewing our insurance plan binders and coverage details.  I am going to start the process this week.  My dh already contacted his hr insurance rep at work and low and behold the man's wife has actually attended a few homebirths as a labor support person.  I think he is going to be a good person to have on our "side".  I am feeling slightly hopeful but know it is probably a long uphill battle.  Thank you again!

[Roanoke midwife]

Thank for all the information.  Can any of you tell me how much your insurance company finally ended up paying for home birth?