Ok, let's talk birth centers and INSURANCE COMPANIES

[Celticqueen]

I am in tears. We are pregnant with our 3rd. First was a typical induced hospital birth, bad experience. Second one was a beautiful, perfect waterbirth at Bella Vie Birth Center in Salem Oregon where we lived at the time. We moved to the Portland area 2 years ago so of course, I wanted to find another waterbith center. We did- Andaluz Waterbirth Center. I was overjoyed to find it! But then my dreams came crashing down about 2 hours ago when I was informed that our supposedly good insurance (Blue Cross Blue Shield- which covers 100% within network and 0% out of network) that it will not cover a dime for it.

So I want the low down on insurance companies. There has to be some sort of legislative action that states can take when it comes to giving birth centers more rights. They lose clients every year because of insurance companies screwing them over by not covering their patients, and therefor, patients can't afford it.

And as against universal healthcare that I am...I am now being forced to wonder...what if? What if birth centers had more rights to accept clients if it weren't for insurance companies dictating who can birth there and who can't?

Well, I am tired of it! And I know several other mama's in Oregon that are too, and there has to be more. Is it just the notion still that hospitals are supposedly safer so they refuse to cover them? Is it just Blue Cross Blue Shield which until today, I absolutely loved?

Upset, angry, in tears, distraught that it looks like I will not have the dream birth I wanted, like my second birth was. To top all of this off, my DH of course, now wants me to just go to our nearest hospital which has a reputation for uncomfortable beds and strict rules about no co-sleeping.

Homebirth is not an option- DH will never have that.

About to scream!!!  There HAS to be some way around this here...They do have a typically "in network OB" there on staff, but she is only in the Oregon BCBS network, not California's (which is what we have through my hubby's job).

Advice, thoughts, or mutual frustration is welcome! I know crying and being mad doesn't fix anything, but it sure does feel good right now

[XanaduMama]

I'm in Portland too--hi! It sounds to me as though the issue is less birth politics (whether birth centers are safer than hospitals etc), but just a straightforward in-network/out-of-network issue. It sucks that your insurance covers 0% of out-of-network: that's the big problem, I think. You might be able to appeal for gap coverage if there aren't any other birth centers in town that they do cover...maybe someone else can help with advice about that. You might want to browse around in the Homebirth forum--gap coverage and other appeals come up there quite often.

So: assuming you can't get coverage, your options seem to be

(1) Find another waterbirth center in PDX that works for your insurance. I believe there are some, and you might want to post in the OR Tribe to see if anyone has recommendations. Hey, even Salem isn't too bad of a drive--might be worth considering, especially if you had a great birth there before

(2) Try for a CNM birth in a hospital (do any offer waterbirth?)

or

(3) Try to talk your dh into HB, which is the option I would strongly recommend . Ironically, I bet your BCBS plan covers homebirths, even if it doesn't cover this particular birth center. Make him watch The Business of Being Born, give him some studies about HB safety, and if all else fails, put your foot down!!

[AlexisT]

There are a few potential issues here.

1) In and out of network. The BC may not be able to accept the contracted fee and as such will not contract with BCBS. Since you have 0% out of network, I am guessing this is an HMO - sometimes the HMO reimbursement is lower than the PPO, and a provider will only accept the latter. In this case, you could try petitioning for an exception if there are no in-network birth centers. If there are (even if you don't like them) you don't have much recourse as far as I can tell--just like I can't demand they pay for the OB I really like if there's another one available.

2) I am from the East Coast, but as I understand it, birth centers in OR may be operated by CPMs. Some insurers only cover nurse-midwives (I still hear of a few that don't even cover that, but most insurers follow CMS' lead, and several states mandate coverage for CNMs/APNs). In that case, it is a specific policy decision and you would need to lobby your insurer to change that policy.

3) Your insurer has a policy of not covering birth centers. Again, that would require lobbying for change.

So, you need to know why this BC is not covered before you can work on changing it.

As for mandating change through the law: The state can only mandate that a category of providers be eligible for reimbursement. They cannot demand that specific providers be contracted. So if, like some insurers, they cover CPMs or BCs but have a poor reimbursement rate so hardly anyone takes it, it's completely legal under a mandate. (They always need to have someone on their list so they can say they really cover whatever it is.)

ETA: Also, BCBS is actually a network of plans, and each BCBS insurer makes its own decisions about what to cover. So my Blue Shield plan covers CNMs (in any setting) and birth centers, but does not cover CPMs (who are not licensed in this state--though some CPMs do manage to bill them successfully).

Edited by AlexisT - 5/17/11 at 11:23am

[lawyer4midwives]

As a general matter, health insurance and managed care have been slow to include home birth, licensed midwives, or birth centers as covered services or providers.  Part of the problem is that managed care plans do not contract with health care providers who do not carry malpractice insurance and not all out-of-hospital midwives carry malpractice insurance.  But a bigger part of the problem is that most health insurers and managed care plans tend to be pro-doctor or, worse, have a medical director who is determined not to allow non-traditional practitioners to become participating providers.  And then, as you may have found, some plans have programs that do not cover out-of-plan practitioners.

Some states have passed laws that require managed care plans and insurance companies to cover LMs and out-of-hospital birth.  Just TODAY, in fact, the governor of Vermont is scheduled to sign a bill that will create such a law in that state.  How did that happen?  Well, consumers joined together with their midwives and a public interest group called Vermont Public Interest Research Group or PIRG to lobby the state legislature and governor to get the law passed -- and they won, just as the Big Push for Midwives is helping other states lobby for licensure laws.  Google the Vermont Midwives Alliance and you can get in touch with them and find out how they did it.  You can do the same -- you just need to start a Friends of Midwives, Friends of Birth Centers, or Oregonians for Safe Birth (or some such name) grass roots group, come to us at the Big Push, and we'll help you get started.  You could also contact Vermont PIRG's health director, Cassandra Gekas (see their website) to get the name and an introduction to her counterpart in Oregon.

Last year, Congress passed a law that mandates that Medicaid (a state/federal program) MUST cover birth center services, and the services of midwives who work in birth centers, for all Medicaid recipients.  So, if you were on Medicaid, this service would be covered.  A bill is currently pending in the federal Congress in Washington DC, HR 1054, which mandates that all state Medicaid plans must also pay for licensed midwife services.

Finally, the new health care reform law that was passed last year contains a provision that requires all insurance companies and managed care plans that participate in the insurance exchanges that will be established under that law by 2014, MUST pay all health providers who are licensed under the law of the state where the provider and insured person is located.  So, by 2014, I would imagine that all insurance companies and managed care plans will simply start paying everyone who is licensed -- if the health care reform law is upheld.

How does any of that help you right now?  Well, not directly. But here are some ideas.  First, I know about Andaluz -- it's an excellent birth center with great midwives, and it would be a shame if you could not have your baby there.  Do you get your insurance through work or your partner's work?  Then, complain to the Human Resources Division and get your co-workers to join with you -- maybe a petition?  Write a letter to the president of Oregon BCBS and enclose the petition, and send a copy of the letter to your state insurance department. Contact a group called "Where's My Midwife?" in North Carolina.  They have a website and facebook page.  Ask them for advice on starting a consumer group that takes sort-of dramatic public action.  Check out their videos on YouTube, especially their flashmob video.  Mothering dot com is a great community, but you will not change the law or the world or anyone's mind who has the power to make the changes you want by crying or complaining to friends.  Cry, get over it, get mad, take action.  Mothers Against Drunk Driving started out as 4 or 5 women sitting over coffee who had all lost family members or friends to drunk drivers.  Look at what they accomplished.  You can do this too.  After all, you have given birth -- you can do anything you set your mind to.

[member234098]

.  

Edited by member234098 - 6/6/12 at 5:38pm

[Celticqueen]

Originally Posted by lawyer4midwives 

As a general matter, health insurance and managed care have been slow to include home birth, licensed midwives, or birth centers as covered services or providers.  Part of the problem is that managed care plans do not contract with health care providers who do not carry malpractice insurance and not all out-of-hospital midwives carry malpractice insurance.  But a bigger part of the problem is that most health insurers and managed care plans tend to be pro-doctor or, worse, have a medical director who is determined not to allow non-traditional practitioners to become participating providers.  And then, as you may have found, some plans have programs that do not cover out-of-plan practitioners.

Some states have passed laws that require managed care plans and insurance companies to cover LMs and out-of-hospital birth.  Just TODAY, in fact, the governor of Vermont is scheduled to sign a bill that will create such a law in that state.  How did that happen?  Well, consumers joined together with their midwives and a public interest group called Vermont Public Interest Research Group or PIRG to lobby the state legislature and governor to get the law passed -- and they won, just as the Big Push for Midwives is helping other states lobby for licensure laws.  Google the Vermont Midwives Alliance and you can get in touch with them and find out how they did it.  You can do the same -- you just need to start a Friends of Midwives, Friends of Birth Centers, or Oregonians for Safe Birth (or some such name) grass roots group, come to us at the Big Push, and we'll help you get started.  You could also contact Vermont PIRG's health director, Cassandra Gekas (see their website) to get the name and an introduction to her counterpart in Oregon.

Last year, Congress passed a law that mandates that Medicaid (a state/federal program) MUST cover birth center services, and the services of midwives who work in birth centers, for all Medicaid recipients.  So, if you were on Medicaid, this service would be covered.  A bill is currently pending in the federal Congress in Washington DC, HR 1054, which mandates that all state Medicaid plans must also pay for licensed midwife services.

Finally, the new health care reform law that was passed last year contains a provision that requires all insurance companies and managed care plans that participate in the insurance exchanges that will be established under that law by 2014, MUST pay all health providers who are licensed under the law of the state where the provider and insured person is located.  So, by 2014, I would imagine that all insurance companies and managed care plans will simply start paying everyone who is licensed -- if the health care reform law is upheld.

How does any of that help you right now?  Well, not directly. But here are some ideas.  First, I know about Andaluz -- it's an excellent birth center with great midwives, and it would be a shame if you could not have your baby there.  Do you get your insurance through work or your partner's work?  Then, complain to the Human Resources Division and get your co-workers to join with you -- maybe a petition?  Write a letter to the president of Oregon BCBS and enclose the petition, and send a copy of the letter to your state insurance department. Contact a group called "Where's My Midwife?" in North Carolina.  They have a website and facebook page.  Ask them for advice on starting a consumer group that takes sort-of dramatic public action.  Check out their videos on YouTube, especially their flashmob video.  Mothering dot com is a great community, but you will not change the law or the world or anyone's mind who has the power to make the changes you want by crying or complaining to friends.  Cry, get over it, get mad, take action.  Mothers Against Drunk Driving started out as 4 or 5 women sitting over coffee who had all lost family members or friends to drunk drivers.  Look at what they accomplished.  You can do this too.  After all, you have given birth -- you can do anything you set your mind to.

VERY helpful information, thank you so very much for taking the time to share all of that. Yes, it is through my husband's work and I think that is an excellent idea to contact the Human Resources Division, or the lady who handles all insurance concerns at his job. Petitioning might deem effective as well! I need to see what can be done. 

Andaluz is doing what they can, but they also suggested that I give my case to my insurance myself and that that might work. What do you think? Is it worth a try?

[lawyer4midwives]

Yes, write to the insurance company.  Direct the letter to the president of the company, not just to some "to whom it may concern" patient relations person.  To find out the name and address of the president, you can google the company online, look for its annual report to shareholders, and you should be able to get the name and address of the president and the chair of the board of directors.  In the letter, state what week of your pregnancy you are in, how you are greatly concerned that you will be subjected to unnecessary and expensive interventions in the hospital and that you will hold the insurance company responsible if anything goes wrong if you had no choice but to deliver in hospital.  Then google the information that the Kaiser Health Plan is putting out about unnecessary interventions and suggest to them that they consider what Kaiser has recognized.  Cite also the study by a group called Childbirth Connection (www.childbirthconnection.org) called Evidence-based Maternity Care:  What it is and what it can achieve."  Look online for information about the lower cost of out-of-hospital birth, including lower rates of c-sections and NICU admissions.  The letter should be a combination of persuasive information, consumer protection issues, and indignation.  Send a copy to your state insurance commissioner (another google task) and cc the name of the insurance commissioner at the base of the letter. 

You might also want to take a look at some sample letters-to-your-health-insurance-company/HMO that are floating around online and adapt the language of those letters.

Good luck! 

[Celticqueen]

Originally Posted by lawyer4midwives 

Yes, write to the insurance company.  Direct the letter to the president of the company, not just to some "to whom it may concern" patient relations person.  To find out the name and address of the president, you can google the company online, look for its annual report to shareholders, and you should be able to get the name and address of the president and the chair of the board of directors.  In the letter, state what week of your pregnancy you are in, how you are greatly concerned that you will be subjected to unnecessary and expensive interventions in the hospital and that you will hold the insurance company responsible if anything goes wrong if you had no choice but to deliver in hospital.  Then google the information that the Kaiser Health Plan is putting out about unnecessary interventions and suggest to them that they consider what Kaiser has recognized.  Cite also the study by a group called Childbirth Connection (www.childbirthconnection.org) called Evidence-based Maternity Care:  What it is and what it can achieve."  Look online for information about the lower cost of out-of-hospital birth, including lower rates of c-sections and NICU admissions.  The letter should be a combination of persuasive information, consumer protection issues, and indignation.  Send a copy to your state insurance commissioner (another google task) and cc the name of the insurance commissioner at the base of the letter. 

You might also want to take a look at some sample letters-to-your-health-insurance-company/HMO that are floating around online and adapt the language of those letters.

Good luck! 

I wanted to update!! It looks like Andaluz waterbirth center and I have fought long enough- a whole week now, and the verdict is that insurance got a bit tired of all our nagging, fighting and persistence- they are currently finalizing paperwork to get Andaluz in network!!!! Thank you for encouraging me to not give up and to take action instead of whining about it at home. This just goes to show that stating my case IS affective, and I really hope this is the light at the end of the tunnel. DH is telling me to be a little skeptical though in case something goes wrong or they change their mind last minute, but it's looking good for me 

[hollyknoxville]

@ Celticqueen, I joined this site to get in touch with you but I cannot send PMs for some reason. Can you try to PM me? I'm in the exact situation you were in and need feedback from you on what worked best to get answers. I have BCBS of AL.