Tricare Remote and homebirth

[Calladona]

Ok, this is actually my first post on mothering.com, so bear with me!  I just found out we're expecting our third baby in January.  My first was a c-section and my second a natural VBAC in the military hospital.  We're moving at about 17-18 weeks to Syracuse NY so my husband can go back to school.  I am 95% sure that I'll be Tricare Remote there.

I've been reading threads on here and it's my impression that it is possible to get full coverage of a homebirth with Tricare Remote and a CNM.  I've found a CNM in the area, though I haven't contacted her yet.  I will need to get full coverage (or close to it) as (and please don't bash me or my husband for this) my husband refuses to pay for a homebirth when we can get a hospital birth for free.

Even homebirth aside, I noticed that the alternative provider I'm looking at in NY (actually a really amazing OB who is super natural minded) isn't in Tricare's provider listing.  So, how does this work?  Has anyone been through this?  I want to get things set ahead of time if possible so my transfer of care can go smoothly.

Anyway, any advice you can give would be great - a homebirth is like a dream for me, but really I just want a supportive provider and I really should be able to get that, right?!

[MarineWife]

Out-of-Pocket Costs
There are no enrollment fees and no out-of-pocket costs for any type of care as long as care is received from your PCM or with a referral. Care received without a referral is subject to point-of-service fees. Download the Summary of Beneficiary Costs Flyer for more specific details.

http://www.tricare.mil/mybenefit/home/overview/Plans/LearnAboutPlansAndCosts/TRICAREPrimeRemote?

The point-of-service option would cost you a $300 deductible and then a 50% costshare copay.

http://www.tricare.mil/mybenefit/Download/Forms/TRICARE_Summary_of_Beneficiary_Costs_Br_021011_unlinked.pdf

Since you can't pay any of the cost, you would have to get a referral or find a PCM who does homebirth and is authorized/certified by TC.The last time I spoke to someone at TC about this I was told that they only cover homebirths with MDs, NPs and CNMs who are TC certified. They do not cover homebirth with lay MWs or CPMs. Just because someone is a CNM does not mean s/he is certified through TC for homebirth. If s/he is not in the TC network, s/he would have to apply for TC certification.

TC will only pay $1500 for a homebirth so your provider would have to be willing to accept that as the full fee for you to not pay anything. I don't know how likely that is since most homebirths I've seen are at least $3000. There is some question about whether that's the full payment for all of your maternity/prenatal care and the birth or if that's just for the birth. If that's just for the birth, your provider can bill TC for each prenatal and get more reimbursement that way.

You will have to call TC and ask specifically how all of that works and how much they will pay. I cannot find anything about homebirth in any of their printed info or online. You may need to speak to a supervisor since many regular customer service reps don't know anything about homebirth coverage.

[Banana731]

when i was with tricare overseas (maybe like remote) tricare paid 100% of hb's with out of network midwives with a referral from a doc from the mtf (they were your pcm.)  you can also drop down to standard and use anyone for a hb, but you'll have to pay whatever the standard % is (25 or 30, i think.)

and i second the cs reps at tricare not knowing anything about hb coverage, ask for a supervisor.

good luck!

[Calladona]

Thanks ladies, Still looking for anyone that has direct experience with Tricare Remote...  Also, if a doctor isn't in network on Tricare Remote, is it still possible to get them covered 100%?  I know, I need to call and talk to a supervisor, just looking for any actual experience.  Thanks!

[Max'sMama]

We had a birth paid for by Tricare Prime Remote when my husband was deployed and it was our secondary insurance.  I think one of the caveats you have is that you do better submitting for yourself then having your CNM submit for you.  TPR actually paid before our primary paid and that forced the hand of the primary insurance to pay out.  

[dlm194]

Can't you just switch to Standard for a year?  Your baby can still be on Prime Remote.  I had 2 babies on Standard and paid $25 for the 1st one and $75 for the 2nd one (it was more because I had to pay for a few nights in the hospital since I had  c-section).  Deductibles and cost shares on Standard to not apply to maternity care.  As long as the midwife is a CNM, Tricare will cover it.  Otherwise I'd call Tricare or go to the nearest office to see about getting a CNM assigned for your pregnancy and birth.  Obviously with Prime Remote, you'll have to get referred out for maternity so I can't see it being a big problem.

[kitkatkaddoodle]

I was in Kansas when I was pregnant and delivered to a homebirth midwife who was accepted by Tricare Remote. Thing is that she has to agree to Tricare's coverage plan which may or may not pay her as much as she would normally charge, and it is against the rules for her to accept payment from them and then bill you the rest. My CNM was former military and liked to offer the service to military women, so that's why she accepted the stipulations.

For my second birth, I went Tricare Standard so I could go to my birth center (home birth laws in this area are just horrible) and only paid for the $25 overnight stay. Again, she would have to accept Tricare Standard's payment scale, but evidently it is broader than regular Tricare Prime. Good luck!

[CEG]

Double check whether you would be on Tricare Remote or not... Fort Drum is only about 40 minutes from Syracuse so you may just use regular Tricare.  I'm not at all clear on what the rules are but I wanted to make sure you knew that was a possibility.  I don't think they would send you to Ft Drum for care but I do think you could potentially still use Prime for your care.

[MarineWife]

Originally Posted by dlm194 

Deductibles and cost shares on Standard to not apply to maternity care.

This is not true anymore. It used to be true until 2004 because all maternity care, whether you were Prime or Standard, had to be received at a MTF unless you got a referral out. It still cost if you had Standard. That's why you paid $25 and $75. Even at a MTF, you are charged per day for your hospital stay on Standard. That was changed in the 2004 fiscal year so that you could go to a civilian care provider on Standard without a referral or authorization. I know because I was angry that I had Standard and still had to get my maternity care at Tripler AMC even after the change because I was pregnant before the change took effect. Now the regular deductible and costshares for Standard apply to maternity care.

[dlm194]

Originally Posted by MarineWife 

Originally Posted by dlm194 

Deductibles and cost shares on Standard to not apply to maternity care.

This is not true anymore. It used to be true until 2004 because all maternity care, whether you were Prime or Standard, had to be received at a MTF unless you got a referral out. It still cost if you had Standard. That's why you paid $25 and $75. Even at a MTF, you are charged per day for your hospital stay on Standard. That was changed in the 2004 fiscal year so that you could go to a civilian care provider on Standard without a referral or authorization. I know because I was angry that I had Standard and still had to get my maternity care at Tripler AMC even after the change because I was pregnant before the change took effect. Now the regular deductible and costshares for Standard apply to maternity care.

My babies were born in 2007 and 2011.  In 2007, I paid $25.  I only stayed in the hospital for 1 night after a vaginal birth.  In 2011 (this past Feb), I paid $75.  I stayed several night following a c-section.  The cost shares are a percentage of the allowable charges; I did not pay cost shares.  Tricare paid out over $10,000 for my c-section and they paid quite a bit for the 4 ultra-sounds I had prior to that (ECV attempts).   I was also hospitalized over night for oligohydramnios.  Again, Tricare covered it and I was not expect to pay cost shares (aka a percentage of what they paid the hospital).  If i had to pay a cost share or deductible (other than $25/night), which is typically about 15% of the allowable charges, I would have hit my $1000 catastrophic cap.

I have never gone to a MTF since I've always been on Standard.  I'm not sure why things were different for you but I can only tell you about my experience and assure anyone who reads this that I only paid $25 for each night in the hospital.   

[MarineWife]

Originally Posted by dlm194 

My babies were born in 2007 and 2011.  In 2007, I paid $25.  I only stayed in the hospital for 1 night after a vaginal birth.  In 2011 (this past Feb), I paid $75.  I stayed several night following a c-section.  The cost shares are a percentage of the allowable charges; I did not pay cost shares.  Tricare paid out over $10,000 for my c-section and they paid quite a bit for the 4 ultra-sounds I had prior to that (ECV attempts).   I was also hospitalized over night for oligohydramnios.  Again, Tricare covered it and I was not expect to pay cost shares (aka a percentage of what they paid the hospital).  If i had to pay a cost share or deductible (other than $25/night), which is typically about 15% of the allowable charges, I would have hit my $1000 catastrophic cap.

I have never gone to a MTF since I've always been on Standard.  I'm not sure why things were different for you but I can only tell you about my experience and assure anyone who reads this that I only paid $25 for each night in the hospital.   

Ok, I figured it out. The $25 and $75 you paid were your cost-shares for your maternity care. The daily in-patient fee is the global fee for all maternity care with Standard for a hospital birth.

The chart below outlines the costs for covered services for active duty family members using TRICARE Standard and Extra.

Cost sharing begins after the annual deductible is met
Sponsor's rank is E-4 and below: $50 (Single)/$100 (Family)
Sponsor's rank is E-5 and above: $150 (Single)/$300 (Family)
Costs are determined by the type of provider you see, network or non-network

The costs shown in this chart are for care received outside of a military treatment facility (MTF). While MTF care is usually free of charge, there may be minimal charges applied for inpatient care. Please check with your local MTF for details.

These costs are effective October 1, 2010.

This is from the chart specific to maternity care:

Maternity Care (Office visits and hospitalization for delivery planned in a hospital in an inpatient setting) $16.85 per day ($25 minimum charge)

Note: This is one global fee for all of the maternity care and delivery.
Maternity Care (Office visits for delivery planned in a TRICARE-authorized birthing center) $25
Maternity Care (Office visits for delivery planned at home or another setting)

Network providers:
15% of negotiated rate

Non-network providers:
20% of allowable charges

(my bolding added)

Thing is that she has to agree to Tricare's coverage plan which may or may not pay her as much as she would normally charge, and it is against the rules for her to accept payment from them and then bill you the rest.

This is sort of correct. If she is a participating provider, she can't charge you anymore. However, if she is a non-participating, non-network provider, she can charge you up to 15% above the TC allowable charge in addition to your deductible and costshare. With Prime that may only apply if you use the POS option since you may only be able to get referrals and authorizations to participating providers. Since I've never had Prime I don't know how the referrals, authorizations and POS option work with that. That would be another thing to ask a TC rep.


ETA because I found info specific to maternity care.
Edited by MarineWife - 5/17/11 at 8:40am

[dlm194]

Ohhh!!!  Wait a sec, I think I see where I'm in error.  MarineWife ~ you are saying the provider can charge up to 15 or 20% more.  That makes sense.  The midwives I used the first time accepted what Tricare gave them as a "service" to the military even though they weren't technically network Tricare providers.  With baby #2, I switched to an OB at 38 weeks.  Her office had never even heard of Tricare so it was all new to them.  Maybe since I was begging her help with a vaginal breech birth since my dh was about to deploy and I didn't want to be recovering from surgery, she decided just accept what Tricare gave her. :) She was definitely a "non-participating" provider since Tricare send the check to me and I had to sent it on to her (the accompanying EOB had "non-participating provider" all over too).  Now that you posted that, I do believe she could have charged me more if she had wanted to.

Any tests, hospitalizations, etc are only subject to the $25 per day.  Hopefully that won't be an issue with a homebirth!!

Tricare  posts their allowable charges on their website so you can see what they will reimburse a provider.  I guess the best thing to do is go there and find out what they reimburse and then find out what the provider will accept.  Many will accept what Tricare pays since they are dealing with military families, especially when they aren't too far from a post.  I know that my midwives did homebirths for military women and spouses (even on post!) and accepted what Tricare reimbursed them without technically being in network. 

Even if a provider is not in network, they can only charge 15-20% more of Tricare's allowable charges (on Standard).  So if a midwife normally charges $4000 but Tricare will only "allow" $2000, the midwife can only charge up to $400 more (20% of 2000).  So you shouldn't be looking at thousands out of pocket.  If the midwife doesn't deal with insurance at all, then I'm not sure how you go about that!

[Calladona]

Thanks ladies!  I still haven't found the time to call Tricare, but I did call and leave a message for the midwife I'm looking at.  I need to find out if she's full yet, if we mesh, if she'll take me on, etc...  I appreciate all the info!  I'm nervous about Standard because I get the impression you're more likely to have copays with Standard?  My DH is going to need convincing to pay copays (even small ones) and more than maybe a few hundred dollars is flat out.  I just know I can't get him to agree to that.  So I'm trying to figure out how to get Tricare to cover as much as possible.  I'm not sure if this midwife would be willing to take a rate reduction - heck I don't even know her rates to begin with.  I don't know where that one poster got the idea that Syracuse is 40 miles from Ft Drum - it's more like 80 miles....  Even from closest point to closest point (like super north Syracuse to SW Ft Drum (not even really Ft Drum), it's still 60 miles.  I'd be very surprised if I'm not Prime Remote...

[MarineWife]

Originally Posted by dlm194 

Ohhh!!!  Wait a sec, I think I see where I'm in error.  MarineWife ~ you are saying the provider can charge up to 15 or 20% more....So if a midwife normally charges $4000 but Tricare will only "allow" $2000, the midwife can only charge up to $400 more (20% of 2000).

It's not more than 15% above the TC allowable charge. So, that would mean if TC allows $1500 for a homebirth, which is what I've been quoted by everyone I've spoken with, and your provider is non-participating, the provider cannot charge you more than $225 extra. They don't have to charge you that but they can if they choose. That's in addition to the deductible and cost-share, though.

Using the above example, if you are E-4 or below, that would be a $50 deductible plus a 20% cost-share, $300, plus the $225. The total out of pocket for you would be $575. If you are E-5 or above, the deductible is $150 so the total cost out of pocket for you would be $675.

That is all for a non-participating provider. A participating provider, whether in-network or out-of-network, cannot charge you anything more than your deductible plus cost-share. There would be no additional 15% cost above that. The total cost of that for E-4 or below would be either $275 if in-network (15% cost-share) or $350 if out-of-network (20% cost-share).

All of the above is if you use Standard or Extra.

The cost is different on Standard for a hospital vs. homebirth. With a hospital birth, you only have to pay the daily cost-share for the time you are in the hospital, which is $16.85/day with a minimum charge of $25. That covers all your prenatal care plus the birth. For a homebirth, you have to pay either 15% for an in-network provider or 20% for an out-of-network provider. That's after paying the $50 or $150 deductible. That is so messed up. A vaginal hospital birth costs thousands more than a homebirth but TC will pay for almost all of the hospital birth but only a percentage of a homebirth. WTH?!

It will be different with Prime. The POS option with Prime costs more than Standard because the deductible is $300 and the cost-share is 50%. However, if you get a referral or authorization or whatever TC calls it, you shouldn't have to pay the deductible or cost-share. I'm not sure about the 15% above the TC allowable charge. I don't know if TC would give a referral or authorization for a non-participating provider.

TC Remote should work the same way as Prime so you would need referrals and authorizations or you would be using the POS option.

I hope all of that makes sense. It can be very confusing. I didn't search for the TC allowable charges on the website.

[Calladona]

Ok, so, here's what it seems like  - if I get a homebirth, it's either Prime Remote with an authorization or referral (if a referral, who from?  My assigned PCM?   So I'd have to wait until after the PCS for that?) OR it's Standard with a midwife that agrees to be a participating provider (I'm not sure what that means?).

Otherwise, I'm looking at hospital delivery and if I can't get quick action on an authorization/referral to the provider I've chosen, it might be easier (and not cost that much more) to switch to Standard?  If I'm looking at hospital birth on Standard with an out of network provider, am I only going to need to pay the per-day hospital fee?

Decisions...  I really need to call Tricare - I don't know why I'm still putting this off.

[MarineWife]

Participating provider is a provider who has agreed to accept the TC allowable charge for their services. They can be in-network or out-of-network. If they are in-network, you pay your deductible and then a 15% cost-share of the fee negotiated with TC. If they are out-of-network, you pay your deductible and then a 20% cost-share of the TC allowable charge. I don't know if there is a difference between the negotiated fee with an in-network provider and the allowable charge with an out-of-network provider. It's only with a non-participating provider that you could also potentially be charged the 15% above the TC allowable charge.

With Standard, a participating provider and a hospital birth, you would only pay your deductible and then the $16.85 daily fee for the time you are in the hospital, with a minimum charge of $25. That means if you are in the hospital for only one day, you would pay $25 after paying your deductible. If you are in the hospital for more than one day, you would pay $16.85 per day.

If you don't get a referral and switch to Standard for a homebirth and have a TC certified provider for your homebirth, you would pay your deductible plus 15% or 20% of the TC allowable charge with a participating provider or 20% of the TC allowable charge plus possibly up to 15% above the TC allowable charge. TC will not cover a homebirth with a provider who is not TC certified. That is something that is in addition to their license. If you choose this option, you will need to check with your provider and with TC to ensure that s/he is a TC certified provider.

If you get a referral with Prime, you shouldn't have to pay anything. You get your referral from your PCM.

Your PCM will refer you to a specialist for care he or she cannot provide and coordinate with your regional contractor for authorization, find a specialist in the network, and file claims on your behalf.

[dlm194]

I am absolutely positive I did not pay any deductible with maternity care.  That info I disagree with it.  I used a non-network participating provider (midwife) in 2007 meaning they were not officially in the Tricare network but they file and accept what Tricare gives them.  I only pay $25 for that which included my 1 u/s, bloodwork, provider fee and hospitalization for the birth

In 2011, I had 4 u/s, bloodwork, Group B strep testing, hospitalization overnight and then c-section delivery.  I paid $75 for all of that.  I did not pay anything toward my deductible even for the u/s and hospitalization for dehydration and then, later, c-section delivery.

With a homebirth, Tricare Standard should still cover any testing without applying anything toward the deductible.

For all other non-maternity medical care, I do pay a $300 deductible plus small cost shares ($10-20) for other visits, test.  The catastrophic out of pocket cap is $1000 (so an extra $700 over the deductible).  The deductible is also split over the family members I think it's about $150 for 1 person.  To me its worth not dealing with referrals.  I had no issues switching providers at 38 weeks to attempt a breech vaginal delivery.  I like that.  ;)

Originally Posted by MarineWife 

Participating provider is a provider who has agreed to accept the TC allowable charge for their services. They can be in-network or out-of-network. If they are in-network, you pay your deductible and then a 15% cost-share of the fee negotiated with TC. If they are out-of-network, you pay your deductible and then a 20% cost-share of the TC allowable charge. I don't know if there is a difference between the negotiated fee with an in-network provider and the allowable charge with an out-of-network provider. It's only with a non-participating provider that you could also potentially be charged the 15% above the TC allowable charge.

[dlm194]

Originally Posted by Calladona 

Ok, so, here's what it seems like  - if I get a homebirth, it's either Prime Remote with an authorization or referral (if a referral, who from?  My assigned PCM?   So I'd have to wait until after the PCS for that?) OR it's Standard with a midwife that agrees to be a participating provider (I'm not sure what that means?).

Otherwise, I'm looking at hospital delivery and if I can't get quick action on an authorization/referral to the provider I've chosen, it might be easier (and not cost that much more) to switch to Standard?  If I'm looking at hospital birth on Standard with an out of network provider, am I only going to need to pay the per-day hospital fee?

Decisions...  I really need to call Tricare - I don't know why I'm still putting this off.

Well, the midwife has to be an authorized provider to get a referral to her on Prime or Prime Remote.  That doesn't mean she needs to be in network.  She just needs to be willing to accept what Tricare will give her.  With Standard, it doesn't matter if she is participating or non-participating.  As long as she is a CNM, Tricare will cover at least some of the costs.  Technically, a provider cannot charge you more than 15-20% of Tricare's allowable charges.  That could get sticky if she asks for payment up front vs waiting to submit. 

It doesn't sounds like Standard would work for you  since you might pay for other medical services.  At this point, I'm thinking you need to simply call the midwife to see if she has ever dealt with Tricare.  Hopefully you'll be pleasantly surprised!  I've found most providers willing to work with me being on Standard.  My dh is Tricare Prime Remote (the rest of us are Standard).  I randomly picked a family doctor based on a local recommendation.  They weren't in the Tricare network but were willing to submit on my behalf.  My dh really needed to see a doctor for something about  a year ago so he just called our family doctors.  We expected to have to pay out of pocket but they submitted to Tricare.  To our surprised, Tricare covered it and considers them his PCMs.  I thought he still had to get treatment through a MTF!

[CEG]

Originally Posted by Calladona 

  I don't know where that one poster got the idea that Syracuse is 40 miles from Ft Drum - it's more like 80 miles....  Even from closest point to closest point (like super north Syracuse to SW Ft Drum (not even really Ft Drum), it's still 60 miles.  I'd be very surprised if I'm not Prime Remote...

I lived there for three years and made many trips to Syracuse:)  I think I said 40 minutes as opposed to 40 miles, which is probably more like getting to where I lived in Watertown.  But definitely an hour or less in normal weather.  When I left there (2006) there was a housing shortage and many soldiers were living in Syracuse.

[Calladona]

So an update - I talked to the one CNM in the area who does homebirths and she is booked.  I feel like this is my sign...  I wasn't sure I really wanted to go through fighting for the homebirth anyway...  So...  I am on to figuring out my in hospital options,of which I think there are some great options in the Syracuse area...  Still, should be interesting having to work through referrals/etc to get the provider I actually want.  We shall see!  Thanks again ladies!