Need help with Tricare and homebirth - Page 5

[paniscus]

I posted my update in the other tricare thread but this thread is really more relevant to my situation so here is my update:

Just thought I would update my situation. As it stands now I got the tricare rep at the mtf to say homebirth IS covered no matter what. She could not find an exclusion anywhere and she called a claims supervisor and they didn't even bat an eye - it is covered. Tricare has also approved my cnm even though she is not in network but she is the only one in the area who does homebirth. I am still waiting to hear about her backup ob. Apparently I need a separate referral for the ob - I am not sure if he is in network or not (depends on who I ask) so I don't know how that will go.

So to recap - I am Prime, hb is totally covered, the out of network cnm is approved. : Still waiting to hear about approval of the backup ob. Moral of the story - keep calling back!!!! Thanks for all your help ladies.

CEG - I wouldn't say she was actually trying to help me - I just kept bugging her so she kind of had to.

I feel so much better now that everyone I have spoken with says hb is covered. The rep scared me because she seemed so sure. I just didn't want to end up getting screwed in the end. I just hope the ob approval goes through. I am a little nervous because if he isn't in network then they may want to send me to someone who IS in network but I kind of need this ob since he is the cnm's backup, yk.

[StacyL]

Originally Posted by paniscus

ISo to recap - I am Prime, hb is totally covered, the out of network cnm is approved. :

Hooray! And you didn't even have to switch to Standard - congratulations!

[paniscus]

So far I haven't had to switch to Standard but I am still waiting to hear about the backup ob. I fear it isn't going to be easy. I guess I will have to tackle that next week. As if I don't have enough to do . . .

[True Blue]

What have people gotten Tricare to pay $-wise? I live in NYC and the fees are $5000+. Last I knew, Tricare paid about $1800 to the homebirth midwife. Depending on the arrangement with the midwife, I could be required to pay the difference (it happened to me once with a hospital mw, I signed a contract without realizing what exactly it meant). I don't mind paying 20% (I'm on Standard), but I don't want to pay the $300) Tricare may not cover, and I'm not sure yet if the midwives will take what Tricare pays or if they will want their full fee in the end.

[wwisdomskr]

Yeah, TriCare only paid our mw's about $1000 for dd2's birth...and told them that they could not bill us for anything more. We were soo mad. Of course, we couldn't afford to pay anything else then, because we hadn't planned for it. I think the mw practice wrote the rest of it off.

This time, we're using a different mw (our primary mw from dd2's birth moved out of the country) and we decided to just pay her full fee out of pocket and then try to get reimbursed after the birth. I seriously cannot deal with the anxiety of dealing with TriCare's bs. We took out some home equity to cover the cost.

But,...the lab did bill them for my bloodwork and I'm still waiting to get a statement for that. (I switched to standard for dd2's birth because that was supposed to make everything covered...while giving me the choice, etc. Whatever...)

Anyway, I think I want an ultrasound and I'm trying to decide how to get that covered, etc. We were planning not to have one...but, we were also planning not to birth anymore children! I'm having a really difficult pregnancy with hyperemesis, stress, etc and I still haven't felt much movement at all. Baby's heart rate has been good by doppler. It's not so much that I think something is wrong...I'm just worried...and I kind of need a bone, so to speak. Maybe that's silly.

I'm thinking of going to a TriCare covered OB in the next town...but I'm worried about getting someone else involved in my business, kwim? Could I really just go in for a 20 week appointment, say that I'm looking for a new provider, get an ultrasound and then just not go back for any more appointments? Would it be that simple?

Thanks in advance for any advice, suggestions, etc.

[wombat]

Originally Posted by paniscus

So far I haven't had to switch to Standard but I am still waiting to hear about the backup ob. I fear it isn't going to be easy. I guess I will have to tackle that next week. As if I don't have enough to do . . .

Congratulations on getting through the military homebirth maze! I'm Prime, in the same area, got the referral, and had it all paid for on Prime. My MTF also didn't have OB facilities.

I didn't have to get any backup OB approval though. My CNM had a backup OB but I never had to see him. Maybe this practice varies depending on the midwife's arrangement with the backup OB?

BTW when your CNM starts billing Tricare, you'll receive billing statements from Tricare detailing all the costs.

Be careful if you choose to have an ultrasound. My CNM doesn't do US and gave me a referral to a ultrasound place but when I double checked it, I found it wasn't in the Tricare approved network. So just because your approved CNM gives you a referral, don't assume Tricare will pay for it. I could find no Tricare approved radiologist to do a Level II ultrasound in my DC/MD/VA area. So I got my CNM to write my referral to the MTF. MTF didn't like that, but I checked with Tricare and basically the MTF HAD TO take me. Tricare/Healthnet head office was incredibly supportive and actually proved an ally against the MTF in my case.

I also had a situation later on in the pregnancy where I was bleeding and during a phone consult with my CNM, she told me to go to the ER. I have a civilian ER and a MTF ER nearby. I went to the MTF ER (better the devil you know kinda thing) and they sent me directly to the birthing area for assessment. MTF didn't like that either, tried to deny me care. I was standing there 8 mo pregnant and bleeding and they tried to tell me to go to a civilian ER. They were very pissy about it. Tricare/Healthnet again supported me, and told the MTF on the phone they had to take me. So just because you have that CNM referral for a homebirth, don't let them tell you you can't access services at your MTF.

Basically I wouldn't believe a thing anyone at the MTF told me about Tricare services. Always check it with Tricare/Healthnet head office.

[True Blue]

I never had any problems with the labs, they were always covered 100%, even with our LM since the labs were in network. Of course, now maternity care is only covered 20% on standard, those bastards. I'm actually considering switching to Prime if they will pay out more money to the midwife, leaving less for me to pay out of pocket (if they only pay the $1800 I'm expecting, and I have to pay 20% of that, then I'm stuck paying like $400 plus the difference in mw fees...but on prime they should pay the $1800 in full then I just have to pay the difference, kwim?

Also, luckily,we are Coast Guard and not near any MTF's!

[StacyL]

Originally Posted by wwisdomskr

Anyway, I think I want an ultrasound and I'm trying to decide how to get that covered, etc. I'm thinking of going to a TriCare covered OB in the next town...but I'm worried about getting someone else involved in my business, kwim? Could I really just go in for a 20 week appointment, say that I'm looking for a new provider, get an ultrasound and then just not go back for any more appointments? Would it be that simple?

Thanks in advance for any advice, suggestions, etc.

Yes, it is that simple. I know I did it.

Even if you have switched to Standard, you can go on base for care at any time - you are just given a very low priority for appts.

Tricare does NOT cover U/S unless it is ordered by your PCM, but it sounds like your PCM would order you one pretty easily since you sound like you are having a rough pregnancy. And as wombat said, it will be done on base at your MTF.

DO NOT have your MW order you an U/S or you will be stuck paying for it. The authorization has to come from your PCM.

[NamastePlatypus]

--------------------------------------------------------------------------------

I have been recently researching whether Tricare pays for home births and I actualy called Tricare yesterday. The woman told me that Tricare does pay for home births under certain criteria:

A. A certified nurse midwife may provide covered care independent of a physician referral and supervision, provided the nurse midwife is:

1. Licensed, when required, by the local licensing agency for the jurisdiction in which the care is provided; and

2. Certified by the American College of Nurse Midwives. To receive certification, a candidate must be a registered nurse who has completed successfully an educational program approved by the American College of Nurse Midwives, and passed the American College of Nurse Midwives National Cretification Examination.

B. The services of a registered nurse who is not a certified nurse midwife may be authorized only when the patient has been referred for care by a licensed physician and a licensed physician provides continuing supervision of the course of care.
lll. Exclusion

A Lay midwife who is either certified nurse midwife not a registered nurse is not an authorized provider, regardless of whether the services rendered may otherwise be covered.

I was wondering if this was from the website? Link? I think I can get away with it because of the red part.

[StacyL]

Originally Posted by True Blue

What have people gotten Tricare to pay $-wise? I live in NYC and the fees are $5000+. Last I knew, Tricare paid about $1800 to the homebirth midwife.

I highly doubt that your MW will charge you the RETAIL rate ($5,000) when you are using insurance.

They know that insurance reimbursement is MUCH LESS than retail rate, and they also know that Tricare (govt. rate) is the lowest rate of reimbursement (about $1,400-$1,600).

So, even though Tricare's range of reimbursement may be less than other insurance plans, they most likely would not expect you to make up the difference between the reimbursement and $5,000.

Make sure you negotiate the rate before you sign anything! You may have to pay a little bit, but even if you had to pay, let's say, $1,000 that is still better than $5,000!

[True Blue]

Oh no, sadly the retail rate here is over $7000!!!!

But I have talked to a couple and we will do some negotiating.

[wombat]

Originally Posted by StacyL

Yes, it is that simple. I know I did it.

Even if you have switched to Standard, you can go on base for care at any time - you are just given a very low priority for appts.

Tricare does NOT cover U/S unless it is ordered by your PCM, but it sounds like your PCM would order you one pretty easily since you sound like you are having a rough pregnancy. And as wombat said, it will be done on base at your MTF.

DO NOT have your MW order you an U/S or you will be stuck paying for it. The authorization has to come from your PCM.

Did you have to get an US referral from your PCM? I got mine from the midwife.

Maybe it depends on your situation and the reason for the ultrasound? I know Tricare doesn't pay for routine US. But I know Tricare allowed me 1 US at about 20w. Or was that just because I'm over 36? I'm classed as AMA (advanced maternal age), LOL.

I actually had 2 US because the 1st US found partial placenta previa and therefore they wanted to do another one at about 36w to check it had 'resolved'. In order for Tricare to pay for the 2nd US, I had to submit the 1st US report to Tricare which stated the reason for requiring a 2nd one. Again Tricare/Healthnet head office was very good at explaining what I needed to do. But that was probably specific to my situation (ie AMA, planned VBAC etc).

[wombat]

Originally Posted by True Blue

I never had any problems with the labs, they were always covered 100%, even with our LM since the labs were in network. Of course, now maternity care is only covered 20% on standard, those bastards. I'm actually considering switching to Prime if they will pay out more money to the midwife, leaving less for me to pay out of pocket (if they only pay the $1800 I'm expecting, and I have to pay 20% of that, then I'm stuck paying like $400 plus the difference in mw fees...but on prime they should pay the $1800 in full then I just have to pay the difference, kwim?

Also, luckily,we are Coast Guard and not near any MTF's!

On Prime you pay nothing. But you have the hassle of needing to get the referral from your PCM. The CNM or any other provider CANNOT charge you anything because before they can be approved as your provider, Tricare has them sign a contract requiring them to follow the conditions of the Tricare Prime insurance. And on Prime you pay nothing, even if you want to. If you really want to get around this, you can give your midwife a nice gift at the end.

Tricare Prime pays their insurance amount which is probably less than the midwives rate but if the midwife accepts the Prime contract, then she accepts that Prime insurance rate. Hope that makes sense.

[True Blue]

When you deal with HM midwives, they generally have a contract that you sign that states you owe more than what Prime pays, essentially. But now that Standard has copays, I'd really like to get this done on Prime or something so I won't have to pay as much to the mw.

OK now....so....if I want to do it through Prime, I need a PCM (naturally, my regular DR is considered a "specialist" even though he's an internal/family dr. Ok whatever. Will it be hard to get that referral? I really really really hate Prime and being told who I can and cannot see!!!!!

[Shelsi]

Since when does Standard have co-pays for maternity care? Did it change again? Anyone have the link?

Also make sure the MTF will actually take you even if you are Standard. I switched to standard for this pregnancy to try and get my LM covered. When I got sick with the shingles I needed to find someone who could prescribe me anti-virals and pain meds. I'd read in the handbook that I could be seen on base but would be lowest priority so I called there first. They refused to see me or even talk with me. They said since I was standard there was nothing they could do and I had to go off base no matter what. It was a total nightmare since I never got a regular PCM after switching, I finally ended up going to an urgent care place and got my meds.

[True Blue]

With Standard you didn't need a PCM, you could have called any doctor who had an opening and gone in.

Yep, new rules, those bastards. Maternity care on Standard has a 20% copay. OH no wait it gets better....that's ONLY if you choose a homebirth!!!!!!! http://www.tricare.mil/Factsheets/vi...eet.cfm?id=261

[paniscus]

I just wanted to update my situation in case anyone else reads this and is trying to figure out what to do in a similar situation. I am on prime and needed to see the backup ob just for 1 appt - mostly they handle the paperwork and initial bloodwork and stuff. I am not really sure why - it just is. Tricare wouldn't let me have a referral to both the mw and her backup ob so I called a supervisor (thanks to the wonderful advice I got here). The supervisor told me to have the MTF put in an Evaluate and Treat referral to the ob. It allows me to see the ob for one visit and then up to 5 follow-ups. My global referral is still to the mw.

RE:ultrasounds - I am still not sure if this is correct information or not but this is what I have been told.

1) Tricare pays for "medically necessary" ultrasounds. So as long as it is billed as medically necessary they should pay for it. (Tricare 800#)

2) You can always get a "perscription" for one from the mw and the MTF will honor it. Then it would totally be covered. (Local Tricare rep)

I am anxious to see if they are really going to pay for my ob appt. Also, my uterus was measuring large so they wanted to do an u/s. I mentioned that it had to be billed as medically necessary. The ob's office said it shouldn't be a problem to do it that way. Of course, I haven't actually seen if it is paid yet or not.

Oh, also, it is my understanding that Tricare will pay whatever the mw bills as her global fee. I shouldn't have to pay anything. Again - I am prime.

[wombat]

Originally Posted by True Blue

When you deal with HM midwives, they generally have a contract that you sign that states you owe more than what Prime pays, essentially. But now that Standard has copays, I'd really like to get this done on Prime or something so I won't have to pay as much to the mw.

OK now....so....if I want to do it through Prime, I need a PCM (naturally, my regular DR is considered a "specialist" even though he's an internal/family dr. Ok whatever. Will it be hard to get that referral? I really really really hate Prime and being told who I can and cannot see!!!!!

Tricare will talk to the MW and discuss the Tricare Prime contract with her. Once the MW accepts that Tricare Prime contract, the MW cannot charge you any extra. If she did, she'd be breaking the Tricare Prime contract. Tricare Prime insurance is very clear about this.

Getting a referral under Prime can be tricky. It depends on whether your MTF has OB facilities. If it does, it can be hard, if not impossible, to get the referral. Some people here have been refused. But I have heard of others that have done it - seems to depend on the hospital management and how anti homebirth (or desperate to enforce hospital birth so they can paid??) they are.

Hmm but you're not near a MTF you say? Are you under Prime Remote? I don't know how that works. Call your Tricare regional headoffice (not the Tricare people on a base!!) and ask them. Ask for the medical management dept - the people who do the authorisations. They should be able to explain your options and give you a definitive answer.

[mom3b1?]

Congrats! That's great!

The only MW around here who does homebirth is in network for Tri-Care so I think this'll be easy, as long as they don't get nasty when I go past dates. We'll be on Tri-Care Standard. I don't know how much it'll cover, but if I have to pay for more beyond that I will. I've learned the hard way that the price I pay for hospital births goes way beyond money, so I'll not go that road again. I"m just glad Tri-Care will pay something!

Kiley

[mom3b1?]

Originally Posted by True Blue

With Standard you didn't need a PCM, you could have called any doctor who had an opening and gone in.

Yep, new rules, those bastards. Maternity care on Standard has a 20% copay. OH no wait it gets better....that's ONLY if you choose a homebirth!!!!!!! http://www.tricare.mil/Factsheets/vi...eet.cfm?id=261

It looks to me like I'd have to pay a $150 deductable, and 15% because the MW is in-Network, for my homebirth with Tri-Care Standard. If we chose Prime then I think there will be too many people reviewing my case. I don't want them to tell me that I can't birth at home because I'm a VBACer, or go past dates, or who knows what else will come up this time. My last baby was born at home, and it was so much safer and better for him, I'm just not willing to put another baby through a medically managed birth.

Kiley