Home birth and insurance coverage in NYS

[Caroline0617]

I am 32 weeks pregnant and desperately trying to make my home birth happen.  I have my first appointment with my new midwife next week but I am freaking out because my insurance company is telling me that they will only pay $2,901 total.  I got some sound advice from another woman on this forum explaining that I needed to find out the customary and usual fee that the insurance company will pay for a home birth...that number is $4,601.  They then told me that I need to pay a $200 deductible and an additional $1500 "catastrophic" deductible because the midwife is out of network (particularly interesting because there is NO home birth midwives in their network).  Is everyone paying this kind of money for a home birth?!?!  My insurance company is GHI, so if anyone has experience dealing with them specifically I would very much appreciate the input.  ANY input at all, in fact, is greatly appreciated!    

[HeliMom]

My homebirth was covered under Oxford because of the New York law that requires coverage of homebirths.  I only paid 200 for the birthtub because that wasn't covered. My midwife was out  of network and I was able to get her paid at in network rates because we filed for something special (my brain is failing me  at the moment).    I'm sorry I can't be more helpful.

[CassMom]

If your insurance company covers homebirths but do not have any local providers that do homebirths then you need to talk to a supervisor and get approval for an out of network provider.  It should be possible since they can't offer you a network provider that offers a covered service.  I haven't done this yet for HB but was successful with Tricare Prime covering physical therapy at a place that doesn't accept Tricare at all.  There wasn't a location that offered the particular therapy I needed locally that was in network even though there are plenty of locations covered for physical therapy locally.  I got my doctor to write a referral and then spoke with Tricare about the lack of options for what I needed.  They are currently paying in full for me to go 3x a week without a problem!

[Caroline0617]

Thank you CassMom and HeliMom...I really appreciate your input!  I spoke with a supervisor and it looks like we are going to apply for an exception since no home birth midwife is IN network.  

[themomadance]

I just got my approval letter today from my health insurance company for my midwife who was out of network for my "home/medical care"  - Description = "Routine Obstetric Care Including Antepartum Care, Vaginal Delivery (With our without Episiotomy and/or forceps) and postpartum care"  

My midwife's office made this happen.  I have to pay her a $750 home birth fee which covers her assistant, and some medical equipment such as oxygen and a few other things that she brings - she says sometimes she can get me some of that money back afterwords... I am happy if that is all I have to pay.

I was worried about having a problem with my health insurance company (HIP- Emblem) but it worked out.  

Here are some links that may help you that I saved when I first started looking into a home birth... Best of luck and I hope it all works out for you!!!!

http://www.gentlebirth.org/archives/insurance.html

http://www.julianarts.com/component/content/article/48-general/64-ny-state-supports-homebirth

http://www.gentlebirth.org/archives/CFMInsurance.html

Don't give up!   

[Caroline0617]

Thanks a million for the reply!  Can I ask you where you and your midwife are located in New York?  I like to have as much information as possible when I'm speaking with the insurance company to make my case.  And if you don't mind...what was the total cost paid by Emblem to the midwife if you know?  

[themomadance]

I'm in Nassau County on Long Island.   I am not positive how much they pay her.  It didn't say on the approval paper.  If I find out I will let you know!

[Caroline0617]

Thanks themomadance!  Hugely helpful!  

[Altair]

I had a HB midwife with GHI 3 years ago.  I was not able to get anywhere with the arguing for in-network (so tell me if you do because I'm pregnant again and trying again with them!) but in the end she was able to submit enough expenses to them, that when they subtracted the cat. deductible and all that it came out that I didn't owe her anything.  I don't expect that to happen again since her fee is now higher.  I have no idea what will happen this time.  

[Caroline0617]

I'll let you know how it all plays out.  Congratulations on your pregnancy!  

[Altair]

And if you could PM me the name of the supervisor if you ever get in touch with one that would be great!  GHI is very difficult to manage.  I recently found out that I should have opted for the optional rider, that it would have increased my out of network maternity benefits.  So frustrating none of this is spelled out anywhere clearly! 

[Caroline0617]

absolutely...I will share all info and progress with you.  The whole thing is so outrageous and incredibly frustrating!  Stand by for updates and bear with me! :) 

[tri31]

Thanks for the information. I have been told that my insurance company will fully cover a homebirth if, if and then if. I am trying to make a way forward, anyway. If you don't mind clarifying something for me, I have been told my primary care physician will be "approving" my homebirth. So I have an apt, why him? Does that sound right? 

[Caroline0617]

I was never told to get approval from a primary care physician.  Sounds strange to me, but I gather most things with the insurance company do sound strange!  When I switched midwives I had to get an okay from my previous practice that stated I am leaving their care and giving permission for all of my files to be disclosed to my chosen home birth midwife.  

[tri31]

Originally Posted by CassMom 

If your insurance company covers homebirths but do not have any local providers that do homebirths then you need to talk to a supervisor and get approval for an out of network provider.  It should be possible since they can't offer you a network provider that offers a covered service.  

Hi, I am going crazy trying to figure out this NY homebirth paradox. There are no providers in my area, but my insurer says they will cover a homebirth. The only midwife that I hear is a possibility, is on holiday for the next few months. I have been talking to a provider from out of state. Can an out of state provider be licenced in NY? Is that a requirement if they are an out of network exception? Why can't I find a link to the insurance website that clarifies their policy? I am terrified that if I don't nail down every detail, something will come back to bite me in the &%^$

[tri31]

I am posting this in the event that this information helps another mom secure a homebirth. My prospects are looking pretty grim.

POLICY STATEMENT:

Based upon our criteria, home birth by a certified nurse midwife (CNM) is eligible for coverage under Health Plan Managed Care, Child Health Plus, Family Health Plus and Medicaid Managed Care contracts when the member is essentially healthy and in accordance with the following criteria.

I.

Participating certified nurse midwives:

Requests for referral to a participating CNM for a home birth is eligible for coverage if the CNM is a participating provider who has a collaborative relationship with:

A.

a licensed physician who is board-certified as an obstetrician-gynecologist by a national certifying body (e.g., American Board of Obstetrics and Gynecology); or

B.

a licensed physician who practices obstetrics and has obstetric admitting privileges at a general hospital where the patient will be referred by the CNM if there are complications with the pregnancy; or

C.

a hospital that provides obstetrics through a licensed physician who has obstetrical admitting privileges.

II.

Non-Participating certified nurse midwives:

If there are no participating CNMs under managed care contracts who perform home births, the member can request a referral to a non-participating CNM. (For purposes of this paragraph, CNM also includes certified midwives.)

A.

In order for a referral to a non-participating CNM to be eligible for coverage the following criteria must be met:

1. 1. The CNM has a current license for the state in which they practice, AND

      The CNM has a collaborative relationship with:

      a. a licensed physician who is board-certified as an obstetrician-gynecologist by a national certifying body; or

      b. a licensed physician who practices obstetrics and has obstetric admitting privileges at a general hospital; where the patient will be referred by the CNM if there are complications with the pregnancy or

      c. a hospital that provides obstetrics through a licensed physician who has obstetrical admitting privileges that provide for consultation, collaborative management, and referral to address the health status and risks of his or her patients and that includes plans for emergency medical gynecological and/or obstetrical coverage;

      AND

      1. •  

The CNM has professional liability/ malpractice insurance for no less than $1 million for each individual incident and $3 million in any given insurance year for multiple incidents against the insured (typically stated as $1 million/$3 million) that expressly covers home births.

B.

Requests for referrals to non-participating CNMs will be evaluated on an individual case basis to determine if the requested home birth is appropriate. The evaluation shall include the patient’s health risk and the proximity of the back-up physician or local hospital.

[motherhendoula]

What part of NY are you in Tri31?  I had NO issues with GHI for my last HB - 08 / 2010.   Is it that you cant find a CNM?  PM if you like

[arce]

HI there,

I'm wondering if anyone has any new info on this.  We are in NYC I am pregnant with my third child.  When I first met with our midwife, she told me there was no issue with GHI paying for homebirth.  Apparently there had been some legal wrangling in the past that resulted in an agreement between GHI and most of the midwives in NYC (maybe beyond). 

Just today (just shy of 34 weeks), I was asking if there was anything else insurance-related that I would need to do.  She said we may have a problem with GHI.  They're suddenly not paying according to the agreement.  She told me we'd probably have a fight, but not to worry.  I'm worried!

Has anyone else heard this, or know what's behind it?

Any info would be greatly appreciated!!

[Caroline0617]

Hi...I started this thread way back when I was still pregnant.  We had a totally amazing home birth on March 7th and my little girl is 9 months old this week!  Unfortunately I am still dealing with the GHI nightmare today.  They did pay the "allowable" amount, but I am still fighting to have the entire cost covered, which is pennies compared to what most hospital births cost.  GHI will only cover "in-network providers" 100%.     

I have written numerous letters to both the GHI Appeals Unit and to The Office of Personnel Management, Healthcare & Insurance Office in Washington, D.C.  Currently I am waiting on a final response from the office in D.C, fingers crossed.  My advice to you would be to keep calling GHI to speak with a supervisor and TAKE DETAILED NOTES...time, date, first and last name of with whom you spoke...I made the stupid mistake of writing John, the supervisor, which nobody seemed to know the next time I called...naturally!  Then, write letters...and appeals.  Do everything you can to strengthen your case against them basically.  

It's super frustrating and they're awful.  And I know it's definitely the last thing you want to be dealing with at 34 weeks pregnant! Don't worry about it though, just be a good record keeper and take it one thing at a time!  

Congratulations to you and your family!

[cjeanjot]

hi there,

I'm in the same kind of fight with another insurance company (Cigna)

The only help (and hope) I have is from the NYS Attorney General office, so far they've been super helpful.

Did you try to contact them?