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Need help with Tricare and homebirth - Page 13

post #241 of 366
Quote:
Originally Posted by Abbysmom1 View Post
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.
That's interesting. I had my kids on AD. When I was pregnant with my first my DH was going to Iraq and I had to beg and plead to get an appointment sooner than 12 weeks. I think it was at 10 weeks and I was scolded when I went because I was "too early."

Editing to add: I wanted to have the appointment before he left for Iraq so he could hear the HB and they didn't want to let me.
post #242 of 366
Quote:
Originally Posted by Abbysmom1 View Post
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.
What about the catastrophic cap? I agree that you shouldn't have to be dealing with this hassle. Why can't you just see anyone for now and switch once you get your referral if you want care now?

Quote:
Originally Posted by Abbysmom1 View Post
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.
I had maternity with my 2nd child at Tripler AMC in Hawaii. I saw a nurse at about 9 weeks just to gather general info and get my maternity care binder. I could not make an apointment with an OB or a CNM until I had reached 12 weeks.
post #243 of 366
Quote:
Originally Posted by MarineWife View Post
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.
Our MTF doesn't provide L&D services. But we still had to fight and go through a big hassle. I am still just : they pay for it.
post #244 of 366
If the MTF doesn't provide L&D services and it's a hassle to get a referral, what do they expect you to do? That's such crap! I guess that's when you need to go to the TC office and/or your PCM with a copy of the handbook and show them exactly what it says in there.

Back when I had my 2nd child, I had Standard (always have) but still had to go to the MTF. I got pregnant in 2003 and my ds was due in January of 2004. In 2003, all maternity care had to be at a MTF even with Standard. They changed that rule in December of '03 but since I had gotten pregnant before the change, I couldn't get coverage for anywhere other than the MTF. That only applied to maternity care so things a lot better now, at least.

By the way, a friend of mine who is looking into homebirth or at least birthing at a birthing center with CPMs rather than the MTF was told by the CPM that TC Standard has paid for their births. I'm wondering how that works since it clearly says in the handbook that Standard only covers CNMs and not lay midwives, which it defines as anyone who is not a registered nurse. She said the TC rep told her it wouldn't be covered.
post #245 of 366
My homebirth midwife has got prime referrals for her services here and we are nowhere near remote. She is a CNM though......
post #246 of 366
Quote:
Originally Posted by MarineWife View Post
If the MTF doesn't provide L&D services and it's a hassle to get a referral, what do they expect you to do? That's such crap! I guess that's when you need to go to the TC office and/or your PCM with a copy of the handbook and show them exactly what it says in there.

Yes, this is true and should be pointed out to everyone reading along here.

EVEN IF you are Prime Remote or your MTF has no L&D services, it is STILL difficult to get the referral to a CNM for a HB. Yes, it is covered, but it will be very difficult and you will likely have to fight for it.

This is why it is so important to have all your DUCKS IN A ROW before you go in to ask for the referral. This includes the name of the CNM they will be writing the referral to. If they screw up your first referral, (happens a lot) it is even harder to get it fixed.
post #247 of 366
Quote:
Originally Posted by paniscus View Post
Our MTF doesn't provide L&D services. But we still had to fight and go through a big hassle. I am still just : they pay for it.
:
post #248 of 366
Quote:
Originally Posted by Abbysmom1 View Post
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.
Since you are Prime Remote you will likely end up having no problem getting your referral, but you need to MAKE SURE that your PCM has every little detail of your CNM's info correct when they submit the form.

However, it is NOT TRUE that switching to Standard would be a financial issue. You are covered for all your maternity care and birth - no co-pays.

If you have an ER visit that is unrelated to pregnancy, you would have a $150 co-pay, that counts toward the $1,000 cap. That is a ONE-TIME event. If you had another ER visit unrelated to pregnancy, there is NO CO-PAY.

Any doctor visit while on Standard (unrelated to pregnancy) has a 20% cost-share, and each one counts toward the $1,000 cap.

So, you can NEVER pay more than $1,000 TOTAL for all of your doctor visits in a 12 month period on Standard.

Realistically, how many doctor visits do you make in a year, unrelated to pregnancy? If you are healthy, probably very few so it would cost you very little money to be on Standard. And even if something bad happened (say, you got hit by a bus, or broke your leg) you would only pay $1,000 total because you would reach the cap immediately.
post #249 of 366
Quote:
Originally Posted by StacyL View Post
However, it is NOT TRUE that switching to Standard would be a financial issue. You are covered for all your maternity care and birth - no co-pays.

If you have an ER visit that is unrelated to pregnancy, you would have a $150 co-pay, that counts toward the $1,000 cap. That is a ONE-TIME event. If you had another ER visit unrelated to pregnancy, there is NO CO-PAY.

Any doctor visit while on Standard (unrelated to pregnancy) has a 20% cost-share, and each one counts toward the $1,000 cap.

So, you can NEVER pay more than $1,000 TOTAL for all of your doctor visits in a 12 month period on Standard.

Realistically, how many doctor visits do you make in a year, unrelated to pregnancy? If you are healthy, probably very few so it would cost you very little money to be on Standard. And even if something bad happened (say, you got hit by a bus, or broke your leg) you would only pay $1,000 total because you would reach the cap immediately.
:

The only thing here I'm confused about now is the cost share or copay for maternity care.

Maternity Care

"Under the new law, a woman whose first prenatal visit occurs on or after December 28, 2003, may choose a civilian doctor or midwife for her prenatal care and have her baby in a civilian hospital under TRICARE Standard. This is available even if she lives near an MTF where maternity care is delivered. Under the maternity benefit, TRICARE pays the expenses for prenatal care, labor and delivery, and post-natal care. However, there is a co-payment for maternity care. (my emphasis) The amount varies based on your length of stay in the hospital and your sponsor's status as an active duty or retired member."

Inpatient Deliveries

"If you are enrolled at an MTF and choose not to use the services provided at that MTF, you may dis-enroll in TRICARE Prime, and use TRICARE Standard (you will assume all cost-shares associated with TRICARE Standard). If you do need to go to a civilian hospital or doctor, it will save you money if you find one who participates in TRICARE Standard. (For a more complete discussion of providers who do or don’t participate, see the “Where to Get Care” chapter.) If other than an E1-E4, you cannot enroll in Prime at the MTF for one year." (my emphasis)

Does this mean if you're spouse is E1-E4, you can re-enroll in Prime before a year is up?

Getting Inpatient Maternity Care from Providers Who Participate in TRICARE Standard

"If you’re the wife of an active duty member, TRICARE Standard pays for all of the covered maternity care from your doctor. For the hospital’s costs, you must pay a small amount for each day that you’re in the civilian hospital. These daily rates are subject to change. In fiscal year 2005, it’s $13.90 per day, with a minimum total charge of $25."

Outpatient care with Standard participating providers

"If you are the wife or unmarried daughter of an active duty member, TRICARE Standard pays generally 80 percent of your covered maternity costs. You must pay the other 20 percent, unless you use a freestanding birthing center."

Giving birth at home is considered outpatient.

The maternity fact sheet says $0 for mothers on Prime who choose to give birth at home or as an outpatient. On Standard, the fee for Global Maternity if you give birth in a hospital as inpatient is $0. However, if you give birth at home or as outpatient, the fee is 20% for Standard or 15% for Extra.
post #250 of 366
I've been poking around a little, and I have found a few CPMs (not near me, of course) who are "Tricare Authorized" However, it appears that Tricare has decided that it was a bad idea to authorize these CPMs and is retracting the certification. Some have had their certification retracted already, and some as of yet, have not been affected. That being said, it is unlikely that Tricare will authorize any new CPMs.

HOWEVER! A CPM in Colorado Springs with a number of Tricare patients says this:

"Tri-care is tricky business. In the past, we have been able to file claims and receive paltry reimbursement ($700), but for the past 4 or 5 years we have not been able to successfully file a claim without it being rejected.

That being said, we have had some VERY persistent clients who have found ways to be reimbursed. They speak with the financial dept. way before the birth, get rejected and ask for a higher ranking supervisor to allow them an "out of hospital" birth. Their theory/argument is that since out of hospital births are not covered by Tri-care, they should be able to go out of the Tri-care network. The BIG key is to get the supervisor of higher rank to sign an out of network agreement. Once that is done, the client files the insurance themselves and gets substantially more than the $700. It seems that the higher rank your client is, the more persistent they are and they tend to know how to work through the system better.

Lots and lots of red tape. They will do everything in their power to block the effort, but it can be done. I tend to leave it in the hands of the client, then they determine how hard they want to push."

So, go out there and fight, girls!!!
post #251 of 366
Quote:
Originally Posted by MarineWife View Post
The only thing here I'm confused about now is the cost share or copay for maternity care.
Well, I can tell you from experience (having had a HB on Standard after 2003) that there are NO CO-PAYS for any of your Global Maternity Care. That goes for all the other mamas at our base here who have had HB's on Standard.
post #252 of 366
Interesting, Stacy, because the handbook says Standard only pays 80% for a HB. That's why I posted those quotes from it. But, it seems that some people are able to get TC to at least partially cover a birth with a CPM even though the handbook also says that's not covered. There are always appeals processes and sometimes it's possible to get them to authorize individual cases for various things.
post #253 of 366
Quote:
Originally Posted by mom2mializ View Post
I've been poking around a little, and I have found a few CPMs (not near me, of course) who are "Tricare Authorized" However, it appears that Tricare has decided that it was a bad idea to authorize these CPMs and is retracting the certification. Some have had their certification retracted already, and some as of yet, have not been affected. That being said, it is unlikely that Tricare will authorize any new CPMs.

HOWEVER! A CPM in Colorado Springs with a number of Tricare patients says this:

"Tri-care is tricky business. In the past, we have been able to file claims and receive paltry reimbursement ($700), but for the past 4 or 5 years we have not been able to successfully file a claim without it being rejected.

That being said, we have had some VERY persistent clients who have found ways to be reimbursed. They speak with the financial dept. way before the birth, get rejected and ask for a higher ranking supervisor to allow them an "out of hospital" birth. Their theory/argument is that since out of hospital births are not covered by Tri-care, they should be able to go out of the Tri-care network. The BIG key is to get the supervisor of higher rank to sign an out of network agreement. Once that is done, the client files the insurance themselves and gets substantially more than the $700. It seems that the higher rank your client is, the more persistent they are and they tend to know how to work through the system better.

Lots and lots of red tape. They will do everything in their power to block the effort, but it can be done. I tend to leave it in the hands of the client, then they determine how hard they want to push."

So, go out there and fight, girls!!!
Is this just for Prime, or standard as well? Do you mean they are cutting CPM's off of standard certification?

This is just such a ridiculous mess, but sadly its a mess that I have to get to the bottom of, because we cant afford to be stuck with a $3000 bill because we thought we would be covered. KWIM? :
post #254 of 366
Jumping in to say that while I'm not certain if Ulrike ever worked out her issues w/ Tricare, she did have a healthy baby girl at home on the 7th.

I don't have really have any details beyond that, I just saw it another board. It sounds like the midwife didn't make it for the birth, but was there just after.

I hope she doesn't mind me posting this here!
post #255 of 366
Quote:
Originally Posted by momtoafireteam View Post
Is this just for Prime, or standard as well? Do you mean they are cutting CPM's off of standard certification?

This is just such a ridiculous mess, but sadly its a mess that I have to get to the bottom of, because we cant afford to be stuck with a $3000 bill because we thought we would be covered. KWIM? :
Prime/Standard wasn't specified... And I'm so right there with you - totally can't afford $3000. DH has hesitantly agreed to this, with the stipulation that we know in advance that we won't be responsible for the entire bill (we're still discussing exactly how much we really can afford).

I'm on prime and spoke briefly with TC today. They didn't REALLY answer my questions (of course), but I gather that if they accept it at all, it will be considered POS unless I am able to get my (blockheaded) PCM to refer me... I don't see THAT happening. I always have the option of switching to standard. A whole new can of worms.
post #256 of 366
Quote:
Originally Posted by mom2mializ View Post
I always have the option of switching to standard. A whole new can of worms.
:

Switching to Standard is NOT a can of worms!

Pardon my irritation here, but I don't like this "myth" being perpetuated for people who are trying to learn how to get a HB covered on Tricare.

Switching to Standard is THE SIMPLEST AND LEAST EXPENSIVE WAY TO GET YOUR HB COVERED. POS is the WORST option.

You do one thing.....

...are you ready for this??


.
.
.
.
.


You fill out a disenrollment form!


That's it!

Done!

No referrals.

No paperwork.

Nothing needed on your part.

You then go see the CNM of your choice who is willing to bill Tricare.

End of story.

P.S. If you have been talking to Tricare, again, do yourself a favor and don't waste your precious time talking to any regular customer service rep. Only talk to a supervisor. They are the only ones with the knowledge to definitively answer ALL your questions. If you like, call the one listed in Post #70 of this thread. She is great!
post #257 of 366
I just meant that discussing switching with the woman would be opening a can of worms - not actually doing it.

I'm willing to put up a fight, though, if it means being able to stay on Prime and pay $0, rather than the deductible and 20%...
post #258 of 366
Quote:
Originally Posted by True Blue View Post
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.
No, she knew what she was talking about, I just explained it badly. She was talking about people who are covered on Standard and see a network provider. Non-network providers are under no such contract and the out of pocket cost can be significantly higher.
post #259 of 366
Quote:
Originally Posted by bechand0128 View Post
Jumping in to say that while I'm not certain if Ulrike ever worked out her issues w/ Tricare, she did have a healthy baby girl at home on the 7th.

I don't have really have any details beyond that, I just saw it another board. It sounds like the midwife didn't make it for the birth, but was there just after.

I hope she doesn't mind me posting this here!
I don't mind at all!

I'm actually back on this thread gathering dates as I write a letter, because my referral still did not go through! On 7 Nov, my PCM's office called to tell me that the referral had again been returned to them with a different provider listed from the one I'd been seeing. When K- at my PCM's office called Tricare to find out why they were again refusing the referral, she was told that they had no proof of "continuity of care" because no bills had been submitted by that provider. (What bills should I have submitted? My first appointment after I was finally told I'd been enrolled was 7 Nov!!! Should I have been submitting bills to Tricare back when I was being told I wasn't even eligible?)

My baby girl was born at 11 pm on 7 November, and I still don't have the referral for maternity care!
post #260 of 366
Just want to say congrats on your baby girl!
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