OK... After reading and reading and talking and talking to Tricare, this is what I have found out thus far. I personally have Tricare Prime (more on that in a bit). There are a few scenarios that can play out with Prime. Typically when someone has prime its because they are active duty and have to use the MTF. If your MTF has OB services then you have to use the base facilities. Pretty much your only option is to switch to standard so you can go off base for you home birth care (sorry, don't know a lot about standard). Switching will only affect you the mother, once baby is born, the baby will automatically be on prime. Mother cannot go back to prime for 1 year, the difference is not that huge, totally worth switching so you can have the birth you want. If your MTF does not have OB services then this is where you can get a referral from your on base PCM to a midwife. My husband was medically retired so we have prime and we do not live close to base so my PCM is civilian and I can choose my OB or midwife.
For Tricare to cover a home birth it has to be with a CNM (Certified Nurse Midwife) I was told this over and over. I have heard of some LM but mainly from mistakes on Tricare's behalf allowing it, there still have been a lot of confusion there with moms. Now it depends on "what kind" of CNM you get as far as Tricare goes, out of network, authorized, or in network. Out of network is just that, they are not in Tricare's system and the POS fees apply to this type and can really add up. Authorized is that the midwife, if not already, gets authorized with Tricare. The authorization is just so Tricare can be sure that they are a CNM and they can then cover her services. The midwife does not contractually agree to the way they pay, so you could still be held responsible for the remaining balance that Tricare doesn't pay, you would discuss this with your midwife on a personal basis. But this authorization would allow you to get care from that CNM. The in network is someone that has contractually agreed to Tricare's fees and then this is where the 100% covered part actually applies, no out of pocket for you. Also the midwife cannot charge you 15% more than Tricare allowed, this is that whole 115% rule.
The midwife that I found is not in Tricare's system and she is taking the steps now before I conceive to become authorized and I will cover the rest of the bill rightfully so, because what Tricare pays out is a joke and it is not fair to her. It is worth it to me to pick up some of the bill to get the birthing experience that I want. Im not 100%, but from what Ive read on the global fee that Tricare pays out 50-60% of the total bill and you take care of the rest. Now, In the Tricare system there is lots of CNM's in my area but they are all hospital based. Since they do not offer a CNM for home birth they "have" to approve you one, given she meets the requirements. Just be sure to state this in the referral letter that your PCM sends into Tricare for your midwife authorization. I hope this all wasn't too confusing. If anyone has any questions please ask and I will try to have the answer.
~ Here is what the midwife needs to do to become authorized, call 1-800-232-2345 Ext. 4231
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