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Need help with Tricare and homebirth - Page 12

post #221 of 366
Quote:
Originally Posted by MarineWife View Post
So, that would mean that with TriCare Standard, you'd only pay the $150 deductible plus, possibly, 15% above the TriCare allowable charge for a homebirth or with Prime and a NAS you'd pay nothing or could you still end up having to pay the 15% above the allowable charge?

Sorry if I confused the issue even more with my original post.
Exactly.
post #222 of 366
Quote:
Originally Posted by StacyL View Post
Anyway, no you absolutely cannot be charged the difference (over 15 %) unless you were dumb enough to sign a contract without reading it! But, who does that?

I also wanted to comment that the POS option is the most expensive way to go. Any supervisor will tell you that. When I switched to Standard for my HB, there was no co-pay at all for Global Maternity (now there is a $150 co-pay.) I think $150 is pretty cheap to have your HB and all prenatal care covered!
Wow, was that a dig? Our "contract" to me looked exactly like all the crap every physician has had me sign. And yes, I read it.

At any rate, I can't think of many midwives who would accept Tricare's charges for a homebirth. Especially not in NYC. In fact, I talked with most of them and they wouldn't. So, either we pay the difference or birth at one of the horrid, horrid hospitals here.

Deductibles with Standard are $150 per person, or $300 per family if you have more then one person on Standard (I personally only use Standard and would never use Prime, I don't like being told who I can and can't see, or waiting for "referrals"). They are slightly lower for I believe E-3 and below, maybe $50? But it's not an officer/enlisted distinction.

And, actually, with Standard now, the new rule is you still have a 20% copay if you choose a homebirth, on top of your deductible. They are, apparently, anti-homebirth nowadays. It didn't used to be this way. So, you could pay your $150, plus 20% of Tricare's allowable charge, plus 15% over their charge.
post #223 of 366
Quote:
Originally Posted by True Blue View Post
Deductibles with Standard are $150 per person, or $300 per family if you have more then one person on Standard (I personally only use Standard and would never use Prime, I don't like being told who I can and can't see, or waiting for "referrals"). They are slightly lower for I believe E-3 and below, maybe $50? But it's not an officer/enlisted distinction.

And, actually, with Standard now, the new rule is you still have a 20% copay if you choose a homebirth, on top of your deductible. They are, apparently, anti-homebirth nowadays. It didn't used to be this way. So, you could pay your $150, plus 20% of Tricare's allowable charge, plus 15% over their charge.
I knew there was a difference in deductibles somewhere but can never remember the cut off. I'm terrible at remembering pay grades. I can't even remember my own dh's.

That's good to know about the deductible and copay stuff with Standard and HB.
post #224 of 366
Quote:
Originally Posted by True Blue View Post
Wow, was that a dig? Our "contract" to me looked exactly like all the crap every physician has had me sign. And yes, I read it.

At any rate, I can't think of many midwives who would accept Tricare's charges for a homebirth. Especially not in NYC. In fact, I talked with most of them and they wouldn't. So, either we pay the difference or birth at one of the horrid, horrid hospitals here.

Deductibles with Standard are $150 per person, or $300 per family if you have more then one person on Standard (I personally only use Standard and would never use Prime, I don't like being told who I can and can't see, or waiting for "referrals"). They are slightly lower for I believe E-3 and below, maybe $50? But it's not an officer/enlisted distinction.

And, actually, with Standard now, the new rule is you still have a 20% copay if you choose a homebirth, on top of your deductible. They are, apparently, anti-homebirth nowadays. It didn't used to be this way. So, you could pay your $150, plus 20% of Tricare's allowable charge, plus 15% over their charge.
No, not at all!

As a matter of fact, I hadn't read your post before I wrote mine, and I saw it later and thought, "Oops - she's going to think I'm referring to her!" I meant a general "who does that" because I guess most people would not sign on the dotted line knowing they were being jerked into overpaying. I'm sorry that happened to you and I am sure it must be umcommon.

BTW, how MW's are getting away with charging $7,000 for a HB in NY should be a crime, considering that's about exactly what un uneventful vaginal HOSPITAL birth costs!

Also, yes it's true - most MW's accept Tricare's rate of reimbursement. Obviously, not in NYC - but elsewhere they do.

And no, you do not pay 20% of your HB on Standard. Check the chart linked above. You only pay the $150 deductible.

The best thing for anyone to do who is reading this thread if they are finding the testimonies of those of us who have had HB's on Tricare confusing is to call a SUPERVISOR! They will clear it all up for you!!
post #225 of 366
I am in the middle of a different struggle (to get crappy crappy crappy Tricare to pay for infertility treatment for a Prime Active duty patient, 5 months and counting). But I just wanted to add that I had heard that Tricare's rate of reimbursement was terrible as well. I did some research and it actually pays more than my BCBS PPO for most services. I haven't done a homebirth with Tricare, but in general their reimbursement rates are actually quite good for most things. Remember that most insurance companies only pay less than half of the charge that a provider sends them. You may be able to get the answer from Tricare on how much they pay, or you may have to have your midwife call and find out (they never want to give info out to a patient) but you may be surprised. Good luck everyone.
post #226 of 366
Oh well good StacyL...I didn't think it was like you but I was like, hey! I resent that!!!! It totally sucked. DH and I both looked at it, but it honestly seemed like all the mumbo jumbo any health care provider makes you sign saying you are responsible, yada yada. We were inexperienced then. Tricare really did try to help us out, but we were stuck. Live and learn!!

Oh but actually the cost share for a homebirth with a MW on Standard/Extra has changed, if you scroll down the fact sheet you will see it says (emphasis mine):

"Professional Services Fee (if you choose to deliver at home or as an outpatient)


Standard: 20%1 of the allowable charge for mother. $0 because newborns are considered a Prime enrollee for up to 60 days for cost sharing purposes.

Extra: 15% of the fee negotiated by TRICARE contractor for mother. $0 because newborns are considered a Prime enrollee for up to 60 days."

Now, they only know you deliver at home if your mw bills it as so, of course. What kills me is it also implies that if you deliver in the hospital and go home the same day (isn't that what outpatient means?) then they'll make you have a cost share.??

I don't think hospital births in NYC cost only $7k though, FTR. Everything costs more here LOL!!! They generally accept $5k if insurance pays that much, though, IME. With bridges alone here...it costs my mw $9 each time she comes over to Staten Island from Brooklyn to see me! :.
post #227 of 366

I got it!

Just wanted to chime in and say I got reimbursed (partially anyways) for our homebirth that we had in July with an LM It actually can be done sometimes! We got just a little over $1400 back.
post #228 of 366
Ugh. Ugh. Ugh. Last Tuesday, I went in and got my PCM to give me a referral to the CNM I've been seeing for the past 7 months (I'm due in two weeks). I had already called Tricare and asked about the referral, and I was told that I should just have my PCM refer me for "global maternity"; no problem for my out-of-network provider.

Today, I got two letters in the mail saying that I'd been approved to see a totally different CNM (who, of course, doesn't do homebirths, not that I'd switch at this point if she did). So, I called Tricare to find out what was up. "The OB you selected wasn't in our network, so we assigned you one." No shit my "OB" wasn't in your network. She was, however, covered by my previous insurance, I'm only on Tricare now, because my husband is DEPLOYING, and I'm due in two weeks, and hell if I'm switching providers now. "I followed the instructions I was given. What did I do wrong, and how do I fix it?" (Yes, said with an attitude.) I was told to have my PCM resubmit and that it should say "continuity of care" on the referral, but even then, she couldn't promise they'd approve it. But, I shouldn't be upset, because I can always use the POS option.

Yes, actually, I should be upset, because who in their right mind thinks it's ok to tell a pregnant woman she has to change providers two weeks before she's due? And, why didn't they tell me when I asked them the first time that "continuity of care" was important on the referral? That's why I asked, damn it! :

When I called my PCM to ask them nicely to resubmit, they said they'd actually already submitted it twice, because the first time Tricare faxed them back with an OB, rather than a CNM. She sent it right back with my midwife's name circled. She's now sending it in a 3rd time with the new wording.

Meanwhile, am I just not supposed to be receiving any prenatal care, just because it's not approved? What totally BS. I did contact my Tricare liaison locally (she was out, but I left a message). I got the impression at the family deployment briefing on Saturday that she may be able to help advocate for me if resubmitting doesn't work.
post #229 of 366
BTW, at that briefing Saturday, she did explain that on Standard, Tricare pays 80%, the patient pays 15%, and the doctor agrees to drop the extra 5%. Weird, but apparently, that's how it works.
post #230 of 366
No offense, Ulrike, but that lady didn't know what she was talking about! I've been on Standard for 7 years and sure would love to be paying 5% less LOL!!! It's only a 15% copay if you see someone in the prime network.
post #231 of 366
Quote:
Originally Posted by True Blue View Post
It's only a 15% copay if you see someone in the prime network.
Actually my kids are on standard and their doc is not a Tricare Network provider but they are credentialed with Tricare (they call this "non-network" but not to be confused with providers who are not recognized by Tricare at all) so we can only be charged 15%. I wanted to see a provider who was not credentialed by Tricare (not even "non-network") but as far as Tricare is concerned, these providers do not exist so they will not even deal with them. If a Tricare representative can look up your provider's name in their database, whether they are network or not, they should only be able to charge you a maximum of 15%.

I have literally called Tricare several hundred times in the last few months and this is the most consistent answer I have gotten. I don't understand why BCBS is so easy and cut and dried but Tricare is wildly confusing and all over the place.
post #232 of 366
http://www.tricare.mil/TricareHandbo....cfm?tn=4&cn=3

"Your provider must be certified by the regional contractor as an authorized provider of care under TRICARE Standard for the Government to share the cost of care you receive. Being “authorized” or “certified” is not the same as being a “participating” or “non-participating” provider of care under TRICARE Standard. (See the chapter titled “Where to Get Care” for discussions of authorized providers as well as participation and non-participation.)"

Where to get care

"Being authorized usually means that the providers are licensed by their state, are accredited by a national organization and meet other standards of the medical community."

"Most hospitals and doctors are authorized by TRICARE (check with them, just to be certain). But for other types of providers, it’s a good idea to check with your regional contractor BCAC/HBA/ TSC before getting care to make sure they’re authorized by TRICARE."

I don't think that's the same as being credentialed by TC. It just means that they have to be licensed by the state to practice medicine and probably board certified (although I've been to some physicians who were not board certified and TC has always paid). That's why TC wouldn't cover my HB. My MW is not licensed by my state, although she is licensed in another state. Most MDs are licensed but not always board certified. I have never had TC refuse to pay for anything regardless of the doc I have seen. I have had to pay the doc in full and get reimbursed directly from TC because I was seeing an out of network doc but the service was still covered.
post #233 of 366
I just wanted to say, I have been fighting with tricare myself now over this, and today I got an authorization for a Prime homebirth with a CPM, because and ONLY because she is also an RN. Its that silly little "N" that gets you. lol. Otherwise, I had LOTS of CPM's willing to do a homebirth with only a 20% cost share of the TMAC on standard. The only difference with Prime vs. standard was that I had to get a referral from my PCM who has been folliwing my pregnancy up until now (and who is a CNM anyway) whereas if I was standard I could have just done it.

Also, out of interests sake, whats the Tricare maximum allowable charge for a homebirth anyway? What does the copay usually end up being?
post #234 of 366
Quote:
Originally Posted by MarineWife View Post
http://www.tricare.mil/TricareHandbo....cfm?tn=4&cn=3

"Your provider must be certified by the regional contractor as an authorized provider of care under TRICARE Standard for the Government to share the cost of care you receive. Being “authorized” or “certified” is not the same as being a “participating” or “non-participating” provider of care under TRICARE Standard. (See the chapter titled “Where to Get Care” for discussions of authorized providers as well as participation and non-participation.)"

Where to get care

"Being authorized usually means that the providers are licensed by their state, are accredited by a national organization and meet other standards of the medical community."

"Most hospitals and doctors are authorized by TRICARE (check with them, just to be certain). But for other types of providers, it’s a good idea to check with your regional contractor BCAC/HBA/ TSC before getting care to make sure they’re authorized by TRICARE."

I don't think that's the same as being credentialed by TC. It just means that they have to be licensed by the state to practice medicine and probably board certified (although I've been to some physicians who were not board certified and TC has always paid). That's why TC wouldn't cover my HB. My MW is not licensed by my state, although she is licensed in another state. Most MDs are licensed but not always board certified. I have never had TC refuse to pay for anything regardless of the doc I have seen. I have had to pay the doc in full and get reimbursed directly from TC because I was seeing an out of network doc but the service was still covered.

That's good information. They definitely don't care about board certification. There is only one Tricare network provider in my area listed in the specialty I need but he is not board certified in that specialty- but Tricare doesn't care. As far as they are concerned they have done their job by sending me to a random doctor who decided to become a reproductive endocrinologist despite not being trained (Can you tell I am still mad?). Thanks for the info. Maybe that will help me and hopefully some others.
post #235 of 366
Has anyone had any success getting a homebirth referral thru Prime?

If so, how did you do it, and what procedure codes did they use?

I have been dealing with Tricare for over a month now, and am so frustrated. There are no network CNM's in my area, so I know they have to give me a referral under Prime, but instead they sent me a POS referral and told me that was considered Prime.

There are some supervisors and case managers working the issue for me, but I can't wait much longer. I'm almost 13 weeks and still have not received any care for my pregnancy.

I'm almost ready to give up and see a regular ob. I called 6 in the area before I could find 1 that was still accepting new clients for my delivery month. If I keep waiting, I won't be able to find any decent ob's that are still accepting clients. :
post #236 of 366
I would just switch to Standard!


To the poster above...Tricare pays around $1500 or so for birth.
post #237 of 366
Quote:
Originally Posted by Abbysmom1 View Post
Has anyone had any success getting a homebirth referral thru Prime?

If so, how did you do it, and what procedure codes did they use?

I have been dealing with Tricare for over a month now, and am so frustrated. There are no network CNM's in my area, so I know they have to give me a referral under Prime, but instead they sent me a POS referral and told me that was considered Prime.

There are some supervisors and case managers working the issue for me, but I can't wait much longer. I'm almost 13 weeks and still have not received any care for my pregnancy.

I'm almost ready to give up and see a regular ob. I called 6 in the area before I could find 1 that was still accepting new clients for my delivery month. If I keep waiting, I won't be able to find any decent ob's that are still accepting clients. :
If it helps at all, once an referral is approved/done you can get the number right away by calling Tricare and having them fax it to the provider. That way you won't have to wait for it in the mail. It has typically been 24-48 hours from when my provider wrote the referral to when I was able to get the info from Tricare. Good luck.
post #238 of 366
Quote:
Originally Posted by Abbysmom1 View Post
Has anyone had any success getting a homebirth referral thru Prime?

If so, how did you do it, and what procedure codes did they use?

I have been dealing with Tricare for over a month now, and am so frustrated. There are no network CNM's in my area, so I know they have to give me a referral under Prime, but instead they sent me a POS referral and told me that was considered Prime.

There are some supervisors and case managers working the issue for me, but I can't wait much longer. I'm almost 13 weeks and still have not received any care for my pregnancy.

I'm almost ready to give up and see a regular ob. I called 6 in the area before I could find 1 that was still accepting new clients for my delivery month. If I keep waiting, I won't be able to find any decent ob's that are still accepting clients. :
You CANNOT get a referral for a HB on Prime unless you are on Prime Remote, or unless your base provides no L&D services. End of story.

If you are not on Prime Remote, and your base does provide L&D services, then the only way is to switch to Standard. Don't go POS option - it will cost you A LOT more money.

The fact that you are 13 weeks already and had no care shouldn't be an issue, as most bases will not see you for a pg before 12 weeks anyway without a complication.

If you are Prime Remote, or have no L&D services at your base, you should be able to get the referral to a CNM witout any problems - BUT you have to find the CNM.

What state are you in?
post #239 of 366
Quote:
Originally Posted by StacyL View Post
You CANNOT get a referral for a HB on Prime unless you are on Prime Remote, or unless your base provides no L&D services.

That's what I was going to say I had read. If you are on Prime and there is a MTF near you that provides L&D, you cannot get a referral out. I was going to ask how those of you here on Prime got referrals for HBs.
post #240 of 366
We are considered Tricare Remote. Tricare has acknowledged that they have to give me the referral thru Prime, but are dragging their feet.

I don't want to go Standard, since Travis AFB is over an hour away, and in the past they refused to see me when I was on Standard. If I have a problem, then I have to pay 20% at a civilian hospital, which would be a financial issue since medical care in CA is very expensive. I should not have to go to Standard when something is covered on Prime. I was told that my auth was not being approved because the PCM office did not put any details on the request. They should have stated that there were no CNM in the area that are Tricare auth.

I used to work at the OB clinic at Lackland when I was AD. We saw patients for their first visit starting at 6 weeks, and considered 12 - 13 weeks to be late in getting care.
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