Tricare homebirth - do I have this right?

[kypovan]

Okay, so here's my situation...

I live in an area that has only 1 homebirth midwife around. Luckily, she is a CNM. She is willing to become an authorized Non-Network Non-Participating Provider. Which means that she is authorized through Tricare, but she does not accept the Tricare allowable charge, and can bill more that 115% of it. I'm completely fine with this, as it is better than the 100% I was prepared to pay to have a homebirth.

Her fee is $3,600. According to the research I've done, if I stay Prime, I would have to use the POS option. Which means a $300 deductible (paid to whom? I don't know) oop to me. Then, I will pay her bill in full, and after I turn in my bill, I will get reimbursed 50% of the allowable charge (around here it's $1,600 ish for a VBAC), so around $600. The total OOP for me would be $3,300

If I switch to Standard, I will have no deductible. Insurance will pay her the allowable charge, and I will have to pay her the balance. The total OOP for me would be $2,000.

I know with standard, there are co-pays and such, but there is none for maternity care. So that wouldn't apply to my maternity care, just if I had to get seen for anything else.

I've been on here and looked at pages and pages of posts talking about this. There was a Maternity Fact Sheet that spelled out the fees, but those links are no longer available, and in the TriWest handbook online of Fact Sheets, they no longer have a Maternity one. I did find this link http://www.triwest.com/beneficiary/bolt/home.mvc/details/maternity And the only extra fees that I can find are for a per day cost when staying in a facility. So I'm assuming that they have changed their policy? That information is current as of Jan 2011.

So, is there anyone that has current Tricare homebirth information to confirm all this? If it is true, that it seems obvious that I need to switch to Standard. Of course, all of this is mostly a moot point, as I am 39 weeks pregnant now, and by the time I figure it all out, it will probably be too late. :)

Thanks!

Wendy

[meesh933]

Ugh. I've paid out of pocket for my MW the last two pregnancies. Tricare sucks. If I remember correctly, I was told last time (so, late 2009) that if I went on Standard, they would pay the allowable charge - my $300 deductible. I couldn't convince anyone I spoke to that on Standard there are no deductibles for maternity coverage, even though it says that all over the TC website and handbook. Whatever. In my area, the allowable charge for global maternity care for an OOH birth was around $1200-1300. I think the exact number I ended up quoted for how much they would pay was $993. The CNM I was seeing charged $4800, but could go down to $3200, no lower. So I would have had to write a letter to my TC service center waiving my right to not be charged over 115%, because she couldn't/wouldn't accept that amount. It ended up being cheaper for me to see a CPM much closer to my home, who only charged $2600 total, even though she couldn't get a penny from TC. By the time I factored in gas to drive across town to get to the CNM, it would've actually cost me more to see her, even with TC.

This time, TC doesn't even know I'm pregnant. Oh wait - yes they do. They kicked back the  claim for my ultrasound, so I have to pay for that out of pocket, too. Pain in the butt.

[Just1More]

I don't know for sure about all that, but I do know that often midwives bill one time.  If they bill their services individually, separate appointments, etc, then Tricare will pay more overall.

[elus0814]

I had to go on standard with my last homebirth and will be doing it again. I had to pay 20% of the midwife's fee, which amounted to $5000 (my share was $1000). My understanding was/is that the tricare standard yearly cap for what you have to pay out of pocket is $1000/year but it may be lower based on rank (it is never over $1000/year, even for those who are very high ranking). My midwife is a CNM who is an out of network tricare participating provider. She bills tricare just once, after the birth, for all prenatal care as well as the birth.

So, in your situation, hypothetically let's say your midwife's fee is $5000 and the tricare allowable fee is $3000. Since she is non-participating you could potentially be on the hook for no more than 115% of the tricare allowable fee. Since the tricare allowable fee is $3000 the total she could charge you would be $3450. You would be reimbursed from tricare their allowable fee of $3000 minus your 20% deductible, which would apply towards your yearly cap if you haven't paid that to another provider yet.

It would look like this:

tricare allowable fee $3000

minus 20%

--------------------------------------

$2400

what the midwife is legally allow to charge you as a tricare patient $3450 (115% of her fee)

minus $2400 that tricare will pay you back

----------------------------------------------------------------

$1050 that you would have to pay out of pocket (this goes above your yearly cap because she's a non-particiapating provider)

This is how I understand the tricare rules but if I were in your shoes I would go to the tricare office on base and have a sit down meeting with someone to get all the details hammered out. 

[~Adorkable~]

you may want to come chat with us on the Military Family Life - Groups you will find a lot of ladies that have used tricare for all sorts of births, the topic comes up regularly

[Breed210]

I know I'm a little late but Tricare has changed the Standard policy from the one year wait.. Let's say you switch to Standard for your homebirth, instead of waiting a year to go back on Prime you are allowed a one time change immediately. SO you could give birth and then switch straight back to Prime.

[~Adorkable~]

it is my understanding that the one year wait to switch off standard back to prime is a rank issue, (you have always been able to switch back whenever if you are under E5, meaning E1-E4 only.) others have to wait the year. Do you know this not to be the case anymore?

[Breed210]

It isn't an issue anymore, just changed in the past year. My husband is an E-7 and that is what Tricare told us when I was trying to figure out getting my midwife.. Although it ended up being a moot point since the only HB midwife in the area doesn't accept tricare, lol..

[~Adorkable~]

that would be a welcome change, will look forward to seeing it in writing, i have had my fair share of tricare reps not knowing what they are talking about, time and time again.

[Jenga]

AFAIK, you'd have to get a referral to use a CNM. If you can get that, you can use one on Prime. Good luck getting it though.

That's what I was told from reps here in Maryland. But Standard covers a lot, almost everything. I would love to see the policy on the one-time change!