Homebirth - UHC Choice Plus PPO

[fairydustpink89]

Our original midwife (SW) was GREAT! She charged $4500 for EVERYTHING (birth pool pregnancy checkups, birth, placenta encapsulation, etc). Then, when my partner and I were seriously discussing it, he didn't want to listen to me AT ALL about the homebirth, he just wanted a hospital. So, I called up SW to cancel and found an OB. A couple weeks later, I decided that he had NO voice in this topic: it's my body and he isn't the one pushing it out. The only problem is that midwife SW got booked up. So, I found another midwife. She charges $5350 and I'm not 100% sure what's included since we haven't met with her yet.

My partner is freaked out because one of our neighbors (who is currently 6 months pregnant) flipped his crap when they found out we were doing a homebirth and started spewing all of these "facts" on homebirth. Now, if my research is correct, more women/babies die in hospital births than homebirths.

I think I've finally got my partner on the same boat and then we find out that becuase the midwife is "out of network" my insurance REFUSES to pay a single penny to any midwife. The only in network midwife is almost 2 hours away ONE WAY! And she's cautious about accepting UHC because half the time they STILL refuse to pay her! Can I fight this?

We had the same problem with the first midwife (out of network), but her billing company (Larsen) has a $15 fee to "hack" into insurances to find loop holes. We did this and they lost our form, so we're waiting on a refund...if they can find our payment. And then we MIGHT use them again on midwife #2.

Anyone else have this problem with this insurance?? What do I need to do? Should I just use the long-distance midwife (Seems REALLY unsafe)?

Oh and my out of network deductible if $6K. My current OB (who has made it VERY clear he will induce me at 40 weeks whether or not I have any problems, he's also made it clear I have no choice: either I do it or he drops me) has admitted to not only homebirth being the best/safest option for us, but he's also the backup doctor for most of the midwives here (midwife #1 referred us to him!).

Any info would be greatly appreciated! Sorry for it being so long, I don't have anyone to vent with about this crap!

[mirandamiranda]

Hello, I have the same insurance as you and they are a pain... Have you asked for a 'gap exception'? (Or possibly 'gap exemption' - I have never quite been clear on which it is...) This is for when they have no relevant care provider within a 30 minute drive (at least that is the rule where I am). If you ring them up and ask for this they put in the request to 'care co-ordination' who will then assess it. If they then refuse you (which they did me - they said I could see a midwife who I had already told them does not do home births, so they are a bit useless) you can appeal it, and I got my coverage granted on appeal. I really think they can't ask you to travel 2 hours each way to a midwife, that is just ridiculous. But you do have to fight them, in my experience - they will put you off and put you off in the hope you will give up, so you have to persevere.

I have done this with UHC a few times for various issues so let me know if I can help any further. I am from the UK and I just cannot believe how incompetent and unhelpful insurance providers are here. It is a disgrace.

And sorry to hear you have had people scaremongering your husband - maybe get him to read a good, research based book on the subject to allay his fears. Henci Goer's "The Thinking Woman's Guide to a Better Birth" is a good one, it has a lot of research and clearly sets out the pros and cons of every choice.

Anyway let me know how you get on!

[fairydustpink89]

We are definitely filing for a "gap extension" through the midwife's billing service. There's no reason I should have to fdrive almost 2 hours away for an in-network midwife. Back home in FL, if the insurance didn't have an in-network midwife within 30miles, they'd have to pay for one that I chose as in-network. The problem is, my insurance doesn't know I've left insurance and my dad has let me stay on the insurance due to my kidney disease.

And aren't you shocked at our lack-of-proof, senseless, no proof "guidelines"? I've done major research in US versus UK women's medical care and am disgusted by the US. In fact, because I refused paps/pelvics due to being no risk (other than having the "lady bits"), my doctor dropped me and refused my pills. I don't see any men getting prostate exams for birth control pills...

My kidney function actually went up when I was on the pill and dropped down after I stopped! Needless to say, I got pregnant 7 months later due to not being able to find a doctor, I'm allergic to latex and spermicide so condoms, foams and sprays  are not a choice. Can't wait for a male pill!!

I've had to fight them constantly. 4 years ago I found out that I was born with 1 kidney and called the ins for a list of in-network doctors. Finally made an appointment with the doctor who told me after my GFR (kidney function test) that my insurance was not paying. Eventually, they paid up (It's funny what threatening lawyers will do!). So, I've been fighting them for years. They seem to cover 

Unfortunately, my partner doesn't read ANYTHING unless it's about cars. I have to read things out to him and then he only half-listens. I've made him watch "Being Born in America" and "Pregnant in America" both did wonders on him! Although we're not legally married, we consider ourselves to be. So thanks for calling him my "husband"!! I've been waiting patiently to get married to him for 3.5 years (I knew INSTANTLY he was the one!).

Thanks for the reply! Oh and so far, I haven't had to pay my OB a single penny, but my neonatal-specialist I had to do a $60 copay. No bill has arrived in the mail yet and I last saw my reg ob a little over a month ago and the specialist I last saw 2 or 3 weeks ago! So UHC seems to pay really good for pregnancy!

[mirandamiranda]

Sounds like you have a plan with the nearby midwife - I hope you get the coverage without too much more trouble! Sounds like you have had a hard time with the insurance altogether. I have had only relatively minor issues and it still drives me absolutely crazy. The amount of time you have to spend on the phone, explaining everything yet again to some incompetent person...

And apologies for making assumptions about your marital status - very careless of me. Thank you for being so polite about it!

Anyway good luck with it all, hopefully they will grant you the coverage and you won't even have to appeal. Let me know how it goes!

[MonkeysInk]

I've requested gap exceptions from UHC twice now and have been successful.  Just make sure to get a list of codes (I got them from Larsen) that your midwife might possibly use and submit all of those for approval with your first request.  With my second baby, I wasn't totally clear on this and only the global OB code got approved.  Since I transported to the hospital, neither the homebirth or hospital midwife billed that code and I had to haggle with UHC afterwards to get the claims paid.  Eventually, the claim was paid at the in-network level, but it did take a few months and a few dozen phone calls.  

Larsen offered to do it for me, but I figured that no one is as protective of my money as I am, so I decided to make the calls myself.  Good luck!  I hope it works out for you.

[fairydustpink89]

I actually just got a letter from my midwife (from Larsen who received it from UHC) saying that UHC will no longer cover midwives on new clients (on gap extensions). It also said that UHC is going to drop ALL in-network midwives right now (starting to at least, but within a year they will no longer cover midwives period). So, if you've already had your first prenatal (not interview, but prenatal) with your midwife, you're excluded from this. So, UHC no longer covers midwives. Their reason is to "save money". Homebirth saves them money! 

Sucks because I have a traumatizing past with OBGYNs (I haven't seen 1 since 2008 or 09) and plan on only having 2 more visits with my current OB (a total of 4 visits, since I waited until 12 weeks to go to one) before switching fully to our midwife. I have NOT done any GYN exams since 2008/09.

We've decided to just pay out-of-pocket for the homebirth and, if money gets tight, we'd just do a quickie at the courthouse so I can get on his insurance, which pays 70-100% for ALL midwives.

[mirandamiranda]

Oh no that is terrible! I can't believe they are doing that. I just give up on healthcare in this country.

[fairydustpink89]

It is horrible. Women's "healthcare" is nothing but politics. I'd love to see men's care be treated the same way. The email they sent me is at the bottom of this post.

We're sticking to the midwife and paying her 100% out-of-pocket. I feel that the "perfect" birth is with her. We just came back from an appointment with her. My partner/boyfriend surprised me today though. I think he's starting to want to drop our OB right NOW. The original idea was not to see the midwife again until July-ish, but he made the appointment with her while I did my own dipstick test. (Despite having 1 kidney, there was only TRACE amounts of protein in my urine!!) He's really warming up to hte midwife, just thinks she's a bit too "hipppie" (too laid back, etc.). I think she's PERFECT!!

Email (From LARSEN Billing to Midwives):

Hi Ladies,

United Healthcare (UHC)  has begun enforcing their policy regarding In-Network Exceptions and midwives.  The policy states that UHC will no longer allow GAP requests for midwives or birth centers due to the fact that the member can go to the hospital or use an OBGYN.  If the member would still like to use a midwife or birth center, and their plan provides such coverage, they can use their out-of-network benefits if they have them.

Our VOB (verification of benefits) reps are being told this repeatedly on their calls for exception requests.  If they aren't told this on the initial call, then they are receiving a return call from a supervisor telling them the same thing.  Our VOB Department Manager received a call today from UHC regarding an in-network exception for a client and was told the same thing.  The rep stated that UHC is strictly enforcing this policy and that anyone caught granting an exception to a midwife or a birth center is in danger of losing their job.  She also stated that if an exception was previously granted, they do not have to honor it when it comes to paying the claims. In fact, we have seen several cases recently where UHC has refused to honor the in-network exception and told us to stop appealing.

We have asked about member requests for in-network exception and member appeals.  We have been told that the member has the right to request the GAP exception but UHC policy is to deny the request.  The member also has the right to appeal.  They will not accept appeals for in-network exception denials  from the provider.

Based on this information, the VOB team will no longer call UHC to request the In-Network Exception.  Instead they will automatically attach our Member Request form letter to the member's email along when they send the VOB.  They will instruct the member regarding the steps necessary to request the exception themselves.

I realize that this will be a big change for many of our providers.  In the past, UHC has been good about granting these exceptions.  Because this is so new, we do not know whether the member requests/appeals will be successful. We do know that members' advocating for their own healthcare always carries more weight in general.  If a member is granted an exception from UHC, they should be prepared that it is quite possible it could be later denied and not honored.

Please let me know if you have any questions.

Thank you,

[thermo]

Any more recent experiences with UHC?

[fairydustpink89]

Thermo, I haven't dealt with UHC since this. We've decided to simply pay the midwife 100% of her fees since getting the birth we want is more important to us than being forced to birth in a hospital (plus, it would cost the same amount, but I HATE hospitals and get panic attacks just passing a hospital sign). 

However, we've recently learned that the Newborn Screening Tests (PKU for example) might not be covered by UHC since we're not birthing in a hospital. Our midwife told us there's a 50/50 chance any insurance will cover newborn screening out-of-hospital (she said she's been working on finding a loophole, but most insurances are a pain when it comes to paying up). Without insurance, it'll cost us (in California) $145. If you're going to do newborn tests, I'd suggest asking your midwife about the cost in case your insurance doesn't cover it, especially since State requirements vary, so the cost will also vary. 

I've considered simply birthing at home and sending UHC a large envelope with the midwife's breakdown of fees and a letter after the birth. I highly doubt I'll end up doing it just because in 2008 I found out I was born with 1 kidney and, UHC refused to cover the kidney function tests or the in-network doctor until 2009/10 (I have to have the KFTs every 6 months). That's a different story (and headache).

[fayebond]

We recently got a letter from UHC about our homebirth.  Essentially, they will cover 80% after we meet our deductible for the year, like any other out of network provider.  Aside from sending us letter every month reminding me that I'd save money by going to an OB, its been just fine.  Our midwife can only them for the birth and the postpartum care, and they'll still cover that same part of the birth cost, even though the bill is for that plus prenatal care.  So, in some senses, its like they want you to have an OB for prenatal but if you "end up" at home with a midwife, well, okay fine, they'll cover that.  

I wonder if they are trying to hedge their bets.  On one hand they tell you, no HB isn't really covered, you are taking that risk on yourself so we can't be sued.  On the other hand they cover any hospital things you want to do (ultrasound, labs, etc), so its almost like asking for shadow care and figuring you can have whatever you want as long as they aren't at any litigatory risk.  

But seriously they save so much money by us doing a home birth.  Prenatal care at my old OB was $6000, and that didn't cover the birth ($10,000), or the CS (another $6000 or so), and they had to swallow all of that.  I don't care how much they negotiate, at some point, we're probably going to see the insurance companies begin to be more oaky with HB  in the US just out of sheer monetary incentives, like in the UK.

[thermo]

Do you have HMO or PPO?

[fayebond]

PPO, 

...And the baby isn't born yet so I have yet to see if they will deliver on the $1000 they promised to pay for the birth.  But, UHC has never hasselled us about things (US, labs) rdered by our midwife, or by our pediatrician, so I'm not worried about the PKU testing part.  We can get the pediatrician to ask for it, or my regluar doctor does have  a family practice, so we could ask her if need be.  But we live in Oregon, which is pretty relaxed about homebirth.  Its not mainstream but most doctors have seen it enough to be cooperative with you on getting extra tests, etc: they seem to realize we are responsible parents who are just trying to have the best of both worlds for our kids.

[mommajax]

I have UHC Choice Plus PPO. I requested a gap exception and have yet to hear back. They are expediting my request because when I called it in earlier this month the rep never filed it. I had my midwife's billing, diagnosis and procedure codes with all her info. It takes some phone calls to get it worked out but I am hoping for approval. There is a supervisor named Trinity that I am working with. They don't have any midwives who are in network that do homebirths. It also has to be within 30 miles as the crow flies. Since I already did my research on this and called all the in network midwives they have to approve the exception. If they don't I will appeal and if that gets denied you just go through your state's insurance commission to file a complaint. A lot of work on our part but its worth it in the end and helps make it easier in the future for those who want to do homebirth. It's not about saving money for them...it's an industry set on paying those that lobby for them.

[GISDiva]

Originally Posted by mommajax 

I have UHC Choice Plus PPO. I requested a gap exception and have yet to hear back. They are expediting my request because when I called it in earlier this month the rep never filed it. I had my midwife's billing, diagnosis and procedure codes with all her info. It takes some phone calls to get it worked out but I am hoping for approval. There is a supervisor named Trinity that I am working with. They don't have any midwives who are in network that do homebirths. It also has to be within 30 miles as the crow flies. Since I already did my research on this and called all the in network midwives they have to approve the exception. If they don't I will appeal and if that gets denied you just go through your state's insurance commission to file a complaint. A lot of work on our part but its worth it in the end and helps make it easier in the future for those who want to do homebirth. It's not about saving money for them...it's an industry set on paying those that lobby for them.

I'm about to go down this road too.  My midwife already warned me about the information they gave Larsen (posted above), but today when I got my Verification of Benefits, it gives totally conflicting information.  Do you cover midwives?  Yes.  Do you cover homebirths?  Yes.  Does this plan allow for gap exceptions?  Yes.  But then at the end there's a statement that "UHC no longer gives exceptions for midwives, but you can try anyway."  How does that line up with the three thing you said "yes" to?!?  Ugh.

Keep us posted, I'd love to hear more tips and experiences.  We're fully prepared to pay the whole thing at out-of-network costs since we have enough in our HSA, but it would sure be nice if we didn't have to.

[mommajax]

I just got confirmation of my approval! I called UHC and my midwife is covered at the in network rate. I don't know who Larsen is but I don't deal with them. I have UHC Choice Plus PPO. It honestly was pretty straightforward. I ended up having my baby boy on Feb 1 and due to complications ended up at the hospital but I already received a letter from UHC stating this would be covered too. So looks like it was simple-ish. Good luck to anyone else out there! This is such a relief and I can not stress about this and enjoy my amazing newborn sweetness.

[fairydustpink89]

MommaJax: CONGRATS!!

I didn't have any midwives within 40mi radius. Technically, they should have covered the midwife I chose, but they denied me on ALL paperwork I sent. Oh well. I ended up still doing my homebirth on Oct 5 (1 day after my birthday) 100% out of pocket and it SAVED MY SON'S LIFE.