Homebirth coverage in Texas?

[txgal]

If your insurance covers a midwife/CNM, can they refuse coverage based only on where the birth occured (home)? What if the CNM doesn't carry malpractice insurance? Trying to work my way through the appeals process and don't want to say too much. Thanks

[mamaverdi]

If they specifically say they do not cover homebirth, then your are SOL.

If they say they cover midwives, but do not list the specific location, then I don't see the problem.

Why isn't your midwife helping you appeal?

[alegna]

Actually they can't dictate where a certified practitioner practices.

Who's your insurance company? Why are they currently refusing? We just talked to them a lot until they were sick of hearing from us

-Angela

[kerikadi]

Our insurance has some out of network coverage - of course there is a high deductible but still some coverage. For instance I think when it is all said and done they cover $1,000 and you know what was submitted
This time is a bit different for us. We have the option to set aside tax deferred money to use on medical expenses. I called the company and they don't care who your provider is. The only problem is that we use a debit card and Pat doesn't take cc so what we will do is pay Pat, submit proof of payment to FSA and they will reimburse us. We feel best case scenerio maybe we'll get $3,000 covered between the crappy insurance coverage and the FSA we set aside. We have BCBS and we had them with Avery as well.

Keri

[Emmeline II]

Here's my Texas insurance post:

Private health insurance that pays for maternity care has to pay for birth regardless of where it occurs (though it may be at an out of network rate). At the bottom is a link for gentlebirth; there is a lot of information on that site to help with billing. I'm in San Antonio/Converse; CPMs and DEMs are legal to practice in Texas.

http://frwebgate.access.gpo.gov/cgi-...1999&TYPE=TEXT
Code of Federal Regulations Title 45, Volume 1:

(iii) Attending provider defined. For purposes of this section, attending provider means an individual who is licensed under applicable State law to provide maternity or pediatric care and who is directly responsible for providing maternity or pediatric care to a mother or newborn child.

c) Construction. With respect to this section, the following rules of construction apply:

(1) Hospital stays not mandatory. This section does not require a mother to--

(i) Give birth in a hospital; or

(ii) Stay in the hospital for a fixed period of time following the birth of her child.

(2) Hospital stay benefits not mandated. This section does not apply to any group health plan, or any group health insurance coverage, that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child.

http://www.gentlebirth.org/cgi-bin/q...&maxresults=40

http://www.gentlebirth.org/archives/money.html#HMO

http://www.texasmidwives.com/

From gentle birth:

To get payment from an HMO, I would have the mother call her insurance carrier and request an "in-network midwife." They will
probably tell her that there is none in network, but they have plenty of other options. She will have to stipulate to them that she has researched
the treatment plan and decided that the midwifery model is her preferred treatment plan. Then she will need to say since there are no "in-network," providers I want a "transfer of care (TOC) exception number, or waiver for the services." (different terms for the same thing.) Many company insurance specialists will have the form. If they refuse to consider a TOC you can file for a review for the denial at that point, then appeal, and finally arbitration or State Insurance Board.

And here is the state board site:
http://www.tdi.state.tx.us/consumer/doctors.html

Notice to HMO Patients
Texas law protects your access to medical care.
If you are not satisfied that your HMO is providing you with the medical services
you need, you should write or call your HMO to complain. If your complaint is not
resolved to your satisfaction, you have the right to request that your complaint be
reviewed by a panel that is made up of members who have not been previously
involved with your case. THE HMO MUST MAKE THIS PANEL AVAILABLE TO
YOU.
If you want to know if you have other rights, call your HMO.
For more information call:
Texas Department of Insurance
HMO Complaint Helpline
1-800-252-3439
In Austin, Call 463-6515

For definition of midwfery care and other good info:
http://www.cfmidwifery.org/midwifery/faq.aspx#1

Definition of OB:

"An obstetrician is a physician who has successfully completed specialized education and training in the management of pregnancy, labor, and pueperium (the time-period directly following childbirth)."

If you decide to challege your insurance company to pay for your midife, remember to talk to their wallet and not their ear :smile:. Call up the hospital where they think you are delivering and find out (in detail) what a hopital birth (w/anest., vag and c-sec) costs. Home birth saves them money, and HMOs exist to save money. There is a stickey at the top with hb safety info and check out the WHO because they have a lot of good things to say about midwives.. Call up the hospital where they think you are delivering and find out (in detail) what a hopital birth (w/anest., vag and c-sec) costs. Home birth saves them money, and HMOs exist to save money. There is a stickey at the top with hb safety info.

Here are some links leading to the parts of Title 45 I quoted:

Googled "Code of Federal Regulations", clicked on it, picked Title 45 from the drop down menu, picked Volume 1 - subtitle A - 1to199, clicked 146 Requirements for the Group Health Insurance Market, clicked 146.130
Standards relating to benefits for mothers and newborns., Clicked on Subpart C,

http://ecfr.gpoaccess.gov/cgi/t/text...l=%2Findex.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...5/45tab_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...45cfrv1_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...46_main_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...3.33.1&idno=45

http://ecfr.gpoaccess.gov/cgi/t/text...dno=45;cc=ecfr

[jerawo]

Our insurance covered midwives (didn't specify which type or where the birth occured) as long as they had a tax id, which mine had. They denied the first request for payment for my homebirth some unknown reason. My midwife resubmitted it as a surgical birth and they paid immediately. Completely crazy, but I didn't care as long as she got paid.

[txgal]

I have a PPO with Humana. I was told when I was pregnant that they covered a CNM but since there was not a CNM on the preferred provider list that they would only cover out of network at 70%. We would also be responsible for the $500 deductible/copay. So that is what we prepared for. I have never made mention of it being a homebirth just in case that could be an issue. The initial claim was filed under code 59400 for $6,000. Of that they excluded $5,150 saying that the charge exceeded the allowable amount for the service. They also excluded $261.00 as deductible/copay. Of the $589.00 covered charge remaining they only paid 60% ($353.40).

It was refiled as 5 separate items all under code 59400
1. $850.00-covered charge $780 paid at 60% ($468.00)
2. $353.00-denied (previously paid)
3. $261.00-denied (deductible)
4. $235.60-denied (coinsurance)
5. $4,300.00-denied (charge exceeds the maximum amount allowed by you plan.

I am trying to figure out what exactly the allowable charge is. I realize that $6,000 may be too much, but I can't imagine that they only allow $1369 for a vaginal birth. The $261 and $235 are the $500 for the deductible, right? I also don't know why they only paid the allowable charges at 60% instead of the out of network 70%. I need to call, I just don't feel like I know enough and want to make sure I don't say the wrong thing. What do I need to say/ask specifically and not say? Thanks for the help.

[alegna]

I would call and just play really dumb and make them explain it all to you VERY slowly... Keep asking questions. How much is covered? Well what should I tell my midwife about how to bill this? etc.

good luck!

-Angela

[WendyC]

United Healthcare covered my homebirth CPM (Texas) - we had to write several letters and call many times, but it got paid! Yay! Also, we transfered so they paid the hospital too!

I love United Healthcare now - too bad we can't afford them anymore.

[Emmeline II]

Just wanted to add that my ins (BCBS of Illinois) said that I could only have a homebirth with a CNM or a MD, or a birthcenter birth with a CNM. I had a homebirth with a CPM! The ins call 6wk pp and wanted to know what hospital I delivered at . They put up a fight but my mw got paid in the end.

[mamavegan]

Bumping this old thread because I need some help and live in TX. I called my insurance company today and he was trying to tell me that I couldn't even get standard care (non-maternity) from a midwife unless she was practicing under an OB. He said TX state law didn't mandate that they cover it. He wouldn't say that midwifes are excluded from my coverage either - they're not.

The main info is that there are no midwives in network. He claims that there may be, but they are probably all practicing under OBs thus making them 'invisible.' But I would have to prove that there aren't to claim a gap exception.

Long story short, I spoke to a not very well educated person on the topic and would love to find the specific state laws to prove to him that midwives should be covered under state mandate. I looked at the links above, but was not able to find it.

I'll call and speak to someone else tomorrow, but I'd love to have the laws in front of me to be better prepared with my own argument.