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Sample Appeal Letters for Homebirth Coverage - Page 2

post #21 of 46
I just wanted to update quickly and tell you that after spending some time on the phone with a few UHC representatives, they said that since there are no midwives in-network within 30 miles of me, they can do something called a "gap exception" to get a midwife covered for my home birth. I will find out in 7-10 days what, if anything, is going to be covered. I will let you all know. This information might help another person who has UHC and is trying to get a home birth covered!

Wish me luck!
post #22 of 46
My midwife is the only CNM in the state that does homebirths. She said that because she lives 1.5 hours from me, she will also be billing with the "gap exception" because I am unable to get the services that I require with a midwife anywhere near here (they all only do hospital births w/ OBs).
(I have BCBS)
I will be watching this thread very closely as I am due in 2 weeks (or 4 ) and we have already prepaid my midwife and I am not going down without a fight to get my 70% OON or 80% regular network reimbursement!
Keep us updated gals!
post #23 of 46
This is my first post and hopefully I'm doing it right.
I've been reading this thread with great interest as I'm in the process of trying to get in-network coverage for a twin homebirth from BCBS MA. I've seen other people report also that since BCBS has in-network midwives that they ignore the fact that these in-network midwives either don't provide homebirth, or, in my case, won't treat patients carrying twins. In network my only option is hospital with OB and that just isn't what I'm looking for as long as this pg continues as it has been so far.
I've found an excellent CPM skilled with twins who I adore and am hoping that my arguments will sway BCBS in some way but I know that they may likely continue to blow me off. Their first reply to my request said, in a nutshell, that there are plenty of in-network midwives and I can just use one of them (which I wrote back explaining again that I can't because they won't accept me plus the fact that they are going to save many thousands of dollars by my choice of homebirth over hospital.)
Does anyone have guidance for me on what the Massachusetts or Virginia law is on homebirth coverage? (or where to find it?) or any other ideas or suggestions would certainly be appreciated.
Thanks!!
post #24 of 46
Anyone have any updates on their experiences with BC/BS? I am in Mass and am trying to get my homebirth covered. The rep on the phone said I had to submit an "individual consideration form". Anyone have experience with that?
post #25 of 46
Hmmm, BCBS MA never mentioned an "individual consideration form" to me, could it be plan specific or required by whomever bankrolls your plan? Please share as you find out more, I'm wondering if that's something I need to ask about.

Our BCBS plan seems to only cover CNMs and I am not eligible for their services. CPMs can legally practice here (VA) and I was hoping for a coverage exception since the CNMs who are covered won't take me. So far no dice and no help from hubby's employer who seems totally unwilling to do anything to assist.

But it does rather seem that individual consideration might be needed. Are you working with a CNM or CPM?
post #26 of 46
CNM only deliver in hospitals and technically are the only ones covered on our plan (which is HMO Blue). We are using a CPM as they are the only ones who deliver outside the hospital. They had her "in their system" as in they had heard of her. I'd never heard of this form but we'll see how far it gets me.
post #27 of 46
I wish you good luck...and would love to hear how it goes. I think I'll ask about the form and see what the reps say to me.

My CPM is also already in the BCBS system which I guess makes it less likely that they'll make a mistake and pay. In my area there are CNMs who do homebirth, but they are hogtied by their OB backups in that they aren't allowed to serve twin pregnancies and hence won't care for me. To me it would seem that this is the perfect situation for an exception since HB is something that is covered and my state licenses CPMs. We've got a long way to go on healthcare in this country.

Best wishes to you in your quest.
post #28 of 46
Quote:
Originally Posted by mama2molly View Post
I just wanted to update quickly and tell you that after spending some time on the phone with a few UHC representatives, they said that since there are no midwives in-network within 30 miles of me, they can do something called a "gap exception" to get a midwife covered for my home birth. I will find out in 7-10 days what, if anything, is going to be covered. I will let you all know. This information might help another person who has UHC and is trying to get a home birth covered!

Wish me luck!
Did you have any luck? I too have UHC and would love to know what your experience was. Thanks.
post #29 of 46

Our HB is 100% Covered by Insurance!

I wrote a letter and included a copy of my states law concerning HB coverage and was approved the first time. I kept it to the facts and did not attempt to sway or sell them on the health benefits of HB or midwifery care...what i have noticed with letter writing is that we often spend a lot of time trying to get someone to feel the same way we do, but that just isn't going to happen most of the time and they lose interest in reading your personal stories or "loony crunchy ideas" and send that denial letter instead.

Shortly after getting approved for the coverage, my HBMW was also added to my providers list of In Network Providers...so no one else has to write a letter to have their birth with her in our area!

I will c&p my letter and their response here, but they can also be found on my website www.JulianArts.com

Please feel free to use my letter in any way you would like! Hope it helps!
Justine

Quote:
After discussing my birthing options with my current health care provider, Ms. Jane Doe, CNM of Local Medical Practice, we have decided that a homebirth is the right option for me. I have included a letter of referral from Jane Doe,CNM, which indicates that Ms. Homebirth Midwife CNM, of Homebirth Midwifery Services is able to provide home birthing services.


I would like to begin seeing Ms. HB Midwife right away for my prenatal care. However, under my current insurance plan with HMO Big Shot Insurance, maternity care by Ms. HB Midwife, is not a covered benefit since she is an out-of-network provider. I am writing to request a an exemption to this policy and authorization for full coverage at the In-Network Benefit Level for my prenatal care, homebirth, transfer to hospital if necessary, and postpartum care under the care and supervision of Ms. Homebirth Midwife CNM, of Homebirth Midwifery Services.


Since my current CNM cannot provide these services, I ask you to please consider New York Insurance Law § 4303(c)(1) as it states:


“If an HMO does not have a midwife who assists in home births in its network, it must allow the prospective mother to access such a midwife, so long as that provider meets the minimum requirements of the plan, who is not in the HMO's network.”


Ms. HB Midwife is fully licensed and legally able to provide home birthing services in the state of New York. She has a collaborative agreement with Dr. Nice Guy and Dr. Supportive who are both In-Network Providers under my current insurance plan. These doctors are unable to perform home birthing services themselves, however, they will be available for consultation, collaboration and transfer of care if necessary. I understand that the safest place for induction/augmentation of labor, regional anesthesia in labor, and surgical birth is at a hospital, and if any of these medical interventions becomes necessary, I will be transferred to the hospital.


I sincerely hope that you will grant me coverage at the In-Network Benefit Level in response to this request. I wish to have a well-monitored childbirth that is responsive to my needs and I feel I am best able to obtain that care with a Certified Nurse Midwife who can attend me at my home. I know that HMO Big Shot Insurance is committed to patient needs and providing high-quality, cost-effective care.

For further questions, please feel free to contact Ms. HB Midwife at (xxx) yyy-0000.

Thank you for your consideration,

Justine Julian
Allegany NY


Here is the response I received from HMO Big Shot Insurance dated a mere 2 days later!



December 13, 2007
Dear Ms Julian,
Thank you for your request for home birthing coverage.


We have reviewed the benefit structure and policy coverage of your health insurance coverage. Your request for us to provide coverage of home birthing under your contract is a VALID and REASONABLE service. The claim for services rendered by a licensed practitioner will be adjudicated and processed in accordance with the provisions of your contract.


While we support your decision on home birthing, we would like to make you aware of the following information. There are several issues that are central to question home birthing services.


We are aware that many medical liability insurance carriers will not provide coverage for practitioners when the series is performed at home instead of a medical facility. This is an area you may want to investigate prior to the expected delivery of your child.


We do not examine the credentials of practitioners who provide services to our members who are not participating with us. The quality and experience of the practitioner you select is a personal choice. HMO Big Shot Insurance does not make any claims regarding the quality or experience of practitioners who may perform home birthing.


We asked the physicians who participate in our Credentials Committee to review the issue of home birthing. The Credentials Committee physicians raised several issues. In addition to the above credentialing and liability issues, the physicians were concerned about the care of newborns in a home birthing environment. If a newborn infant requires any special care or emergency treatment, a detailed response plan should be in place at the time of delivery.


Thank you for the opportunity to provide the above details. If you have any questions, please feel free to call XXX-YYY-0000.

Sincerely,
Ms. Almost Supportive, MD
Medical Director of HMO Big Shot Insurance
post #30 of 46
Has anyone had Aetna cover their HB costs?
post #31 of 46
Quote:
Originally Posted by EarthsSpiral View Post
Has anyone had Aetna cover their HB costs?
Hey,
I have no experience with birth, let alone with Aetna, but someone on this thread said that a representative from Aetna said they would pay for it. This is an old thread, but I would hope the information is still a little true.
post #32 of 46

insurance coverage for homebirth

Dear Mamma2Molly,

I have BCBS of MN, but live in New York and we are expecting at the moment. I felt very passionate about homebirth, so was going to do it even if I had to pay myself.

Like you, I wanted to get an authorisation beforehand. Initially, BCBS said 'they would not cover for homebirth', but under my policy I have 'home health care' coverage. So, I called my employer (HR dept) and asked them to deal with it and they did! After a week of phone calls and emails, BCBS called me and said that they will cover homebirth and all other midwife services.

They are processing my first claim at the moment...

So, I my advice would be try getting your employer to talk to them and convince them that it's much cheaper for them to pay for homebirth than for hospital birth.

Also, check out the laws in your state. In NY, midwife services 'must be paid' by HMOs. The only way BCBS was arguing for not paying (in my case) was that they wanted me to go to 'in-network'. Of course, there are no midwives who attend homebirths who are in anybody's network.

If all else fails, you can email their press office and tell them you will publicize their refusal...

Anyway, good luck!
anoric
post #33 of 46

Thanks for quoting me!

Carla
post #34 of 46
Wow! What an awesome, wonderful, and extremely helpful thread. I bookmarked it and will absolutely be using these suggestions. I have Preferred Care in Upstate NY and we have a PPO which covers 60% out-of-network and 80% in-network. Of course, our homebirth midwife is the only one in the entire area and is out-of-network. FWIW, though, she is IN-network with BCBS (kinda cool). Dh and I have been mulling over how to go about getting the 80% coverage rate, and now we definitely have a starting point.

Thanks so much! I will share how it goes for the benefit of others who may have our same insurance!
post #35 of 46
Anyone have any experience with Blue Care Network?
post #36 of 46
Quote:
Originally Posted by kitkatsmama View Post
Anyone have any experience with Blue Care Network?
Are you talking about Blue Shield/Blue Cross?

We have Blue Shield and while home birth is a covered benefit it has to be done with a network provider. Surprise, surprise there are no midwives in network. :

My husband and I payed out of pocked for our homebirth, but I'm thinking about writing a letter to the company that manages the network for Blue Shield locally and asking them to credential my midwife as a provider. I know it will probably be a waste of time though so...
post #37 of 46
Quote:
Originally Posted by lwuertz View Post
Are you talking about Blue Shield/Blue Cross?

We have Blue Shield and while home birth is a covered benefit it has to be done with a network provider. Surprise, surprise there are no midwives in network. :

My husband and I payed out of pocked for our homebirth, but I'm thinking about writing a letter to the company that manages the network for Blue Shield locally and asking them to credential my midwife as a provider. I know it will probably be a waste of time though so...
It's worth a shot. I was able to talk my ins co into covering my home birth midwife as in network because there are not in network *home* birth midwives within like 20 miles of my house (really, I doubt there are any...). Either way, I would think they'd cover you as out of network - will the midwife try to bill it and see what happens? You might be surprised.
post #38 of 46
Didn't get to read all the posts yet but want to sub and read them all. Looks like I need one of these appeal letter to send to my insurance co. BCBS FL with HMO plan. One of the poster earlier said in FL, insurance co should cover HB, can anyone tell me more about it or where I can find more info??
We just got denied our Gap Exception, does this mean they will not cover at all? I'll have to call and find out but want to know from you guys' experience what to expect or what I should do next...
TIA
post #39 of 46
So I'm late on this post but I'd like to share my experience. I wrote an appeal letter which was abruptly denied because they claim that homebirth simply isn't covered. They said it says it in THEIR manual but cannot locate it in mine (which in itself is a crock). Anyway, They are now paying for most of it after lots of work because I argued if they won't pay for the "birth" they need to at least cover the prenatal visits. I am getting a huge portion of it paid for because they pay for the prenatal visits at 100% and they just won't pay for the vaginal birth. Oh, and my midwife is also billing them separately for the well-baby exams. Hope that helps!
post #40 of 46
Oh and if you want it, this is my appeal letter:

February 13, 2009

xxx including
xxx
P.O. Box xxx
Redmond, OR 97756

Dear Sir or Madam:
This letter is in response to the denial of coverage for the prenatal care, labor and delivery, and post partum care surrounding the birth of my daughter, Holly Pittman, on 12/23/08.
After having our first daughter in the hospital in February 2007, we were not satisfied with the care we received and were astounded by the cost of having a simple, non-complicated pregnancy and birth. When I became pregnant with Holly in March 2008, we searched for a better, less costly alternative. Due to the horrifying statistics of unnecessary interventions such as vacuum and forcep delivery, episiotomies, pitocin inductions, and especially that 1 in 4 women are given c-sections, we determined that the healthiest and most cost effective birth option was a homebirth with an attendant midwife.
During our midwife’s first visits, we were insured through xxx's Regence BlueCross Blue Shield plan. Knowing that she had been paid many times through BlueCross, we had little to worry about. Unbeknown to us, our provider would be changing half way through the pregnancy to a new provider. Our new in-house health insurance was supposed to be better and cheaper for everyone. Obviously that is not the case for us, with your recent denial to cover the cost of the birth of my daughter.
I am including a breakdown of the cost to deliver my first daughter in a hospital setting:
$3,515.78 Prenatal/Post partum care and delivery charges paid to midwife, xxx
$6,519.95 Bill from the hospital for Angela
$910.00 Paid to xxx, the anesthesiologist that performed the epidural
$3,100.35 Bill from the hospital for Lexus (new baby)
$1,187.94 Charges incurred for Dr. visits and shots for baby's first 6 weeks
_______________
$15,234.02 TOTAL

Clearly it is in the best interest of the company to keep costs low for health insurance. The cost for an OB/GYN to do the prenatal care, a hospital birth with attending physicians, and the following stay in the hospital, would have cost nearly five times the $4,100 that my midwife Marcene charged for the ENTIRE course of maternal care. I had complete prenatal care, labor and delivery support, post partum care for six weeks, as well as checkups for baby for six weeks.
Aside from the obvious point that it saves thousands of dollars, I'd also like to comment on the quality of service I received from my midwife. From my first appointment to my last at 6 weeks post partum, I felt a strong and loving connection with Marcene. She always made me feel completely comfortable and that she deeply cared for my baby and me. I never felt that with the quick 10 minute checkups at the clinic that I had with my first baby. Marcene was wonderfully knowledgeable and gave me a sense of empowerment throughout my labor, making me realize I am a woman and was made to do this. When baby was born, she was healthy, alert, and ready to nurse. I was able to hold baby for as long as I wanted and wasn't forced into doing anything I didn't want to do. There were no nightime blood draws for myself or my newborn, no IVs, no pills, etc.
I feel like I healed more quickly, bled less, and enjoyed my experience more because I chose to have a homebirth. I also believe the continued support, as well as the more enjoyable birthing experience has helped stave off post partum depression, which in itself can be another long-term costly medical liability.
The representative on the phone told me that home births are not covered. I urge you to ask why that is and to reconsider, for the numerous reasons stated above, as well as countless other benefits to having your baby at home.
Thank you for reconsidering coverage of the birth of my daughter.
Sincerely,
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