Insurance can deny homebirth?

[bygones75]

(crossposted in Oct 07 -- it was recommended to me that you ladies might be able to help me.)

Any lawyers/ law-smart women on here?

My insurance company not only just told me that I couldn't have a homebirth under their plan, but that midwives in general aren't covered either. I've been seeing a (hospital) midwifery group this whole pregnancy, and they're just telling this to me now.

I talked to the homebirth midwife, who said under NY law, insurance companies are required to cover homebirth. She faxed me the law in detail, which I'll pick up tomorrow. My insurance company is based in Texas, because that's where my husband's company is. But if they're operating in NY and have NY patients, don't they need to abide by its health laws?

The midwife said she's never heard of this happening, but BC/BS is constantly putting me through the wringer. (Like when my husband had a tumor removed from his spinal cord, they paid $147.00 of it. P.S. It was a $45,000 surgery.)

Ok, I'm getting off-topic. I guess my question is, what do I do now? Do I have to hire a lawyer? I really don't have any money. The midwife said I could call the attorney general's office and the Dept of Health, which I'll do, but I just want to take the right route and not waste time. I'm tired of fighting with them.

Any ideas are really appreciated.

[mwherbs]

the insurance commissioner in your state- is a place to look and lodge a complaint to -- here is a web site--
http://www.ins.state.ny.us/

and here is a resource for anyone else who may need to look at their insurance commissioner's office

http://www.patientrights.com/links/links7.htm

[bygones75]

Thanks. I just wrote a letter to them now.

[MamaVolpe]

I would get a copy of your EOC-Evidance of Coverage booklet to see exactly how the benefits are worded. If not listed as a specific exclusion on the policy then you have room to fight it. One thing to check do you have and HMO, POS, PPO or Indeminty plan? If HMO make sure your providers are In-Network or else they may refuse to cover the services based on the no coverage for non par rules.

Also see if you can find out the exact reasons for the denial. When they told you that you weren't covered were you just asking for benefits or was this an authorization for services that was denied. If it is the former then dont stress too much, a lot of insurance reps just dont know if homebirth is covered or not, so they just assume not. That does not mean it is not covered it just means that they don't know. Most insurance policys dont put anything in their policys that discusses homebirth since it is so infrequently requested. As long as it is not specifically excluded you should be able to get coverage.
If it is an authorization for services that was denied then you would want to submitt an appeal.

Good Luck

[lyttlewon]

Originally Posted by mwherbs

the insurance commissioner in your state- is a place to look and lodge a complaint to -- here is a web site--
http://www.ins.state.ny.us/

and here is a resource for anyone else who may need to look at their insurance commissioner's office

http://www.patientrights.com/links/links7.htm

After being denied by Aetna for homebirth I called my insurance commisioners office. They explained that since my insurance is self funded, meaning my company is self insured, then Aetna is not bound by my state law. I haven't sent in the appeal papers yet from my denial I really don't have the energy to fight anymore.

[bygones75]

[QUOTE=MamaVolpe;8069968] One thing to check do you have and HMO, POS, PPO or Indeminty plan?

PPO. Their reason for the denial was that "my plan doesn't cover it." Not very specific. DH is going to call Human Resources tomorrow and also email me a copy of the EOC.

There are no in-network homebirth midwives under BC in my state. So I was hoping for an "in-network exception"... not to be told that I couldn't have a midwife at all. I did talk to a supervisor who told me the same thing. But they're so full of crap there that I know I'll have to do the research for myself.

Thanks for your help!

[bygones75]

Originally Posted by lyttlewon

After being denied by Aetna for homebirth I called my insurance commisioners office. They explained that since my insurance is self funded, meaning my company is self insured, then Aetna is not bound by my state law. I haven't sent in the appeal papers yet from my denial I really don't have the energy to fight anymore.

I just found out about the "self-funded" deal myself.

Sorry you're going through this too. And I know what you mean about not having the energy.

[lyttlewon]

Originally Posted by bygones75

I just found out about the "self-funded" deal myself.

Sorry you're going through this too. And I know what you mean about not having the energy.

Can you still have the birth? I have the money to pay for it. At first DH was resistant to the idea of paying for it and I totally freaked out. He ended up saying that he didn't mean to upset me and he just wants me to be happy :. I thought it was amazing how you can be with a guy for 11 years and he can still do things that melt your heart.

[bygones75]

Sounds like a good DH to me.

We can't do it if it's 6K... that's just beyond us. If she'll come down a few grand, I probably could. Trying to swallow my pride and get the courage to ask her.

I did buy lotto tickets today. I won $4. Ah well.

[USAmma]

Yeah we have an issue with the self-funded thing, too. Under AZ law, people with my dd's condition are supposed to get 75% coverage for the medical food (formula) they require, but since our insurance is self-funded they don't have to comply with the law. It's really awful. Good luck with the letter writing.

[JustKiya]

Originally Posted by bygones75

Sounds like a good DH to me.

We can't do it if it's 6K... that's just beyond us. If she'll come down a few grand, I probably could. Trying to swallow my pride and get the courage to ask her.

I did buy lotto tickets today. I won $4. Ah well.

Ask about a payment plan/barter/trade - something for the amount you want/need her to come down....



Good Luck!!

[mwherbs]

well the other thing we probably need is a list of self-funded insurance companies so we can not be purchasing their insurance-- complain complain complain-- that is what I say-- what are we paying them for if they don't try to meet our needs!

[katsam]

Yep, that is exactly what BC/BS told me.
My midwife told me it is because they are physician owned and operated or something like that, and that is why they therefore won't pay for midwifery services.
They also tried to not pay a big hospital bill for my ds, but ended up doing so after we called enough times.

[HeatherB]

Do they cover ANY midwives? My plan (UHC PPO) has coverage for midwives with a couple in-network locally (in-hospital, of course). There's also a column for out-of-network midwives, so I called and confirmed my coverage for that. When they had NO problems with that, I then confirmed that they didn't care WHERE I birthed. Other than some technical issues (wrong year on part of the claim!) everything went smoothly the first time.

All that to say, maybe don't ask about HOMEBIRTH, but just MIDWIVES. See if that helps, maybe? Hopeful for you!

[bygones75]

Originally Posted by HeatherB

Do they cover ANY midwives? My plan (UHC PPO) has coverage for midwives with a couple in-network locally (in-hospital, of course). There's also a column for out-of-network midwives, so I called and confirmed my coverage for that. When they had NO problems with that, I then confirmed that they didn't care WHERE I birthed. Other than some technical issues (wrong year on part of the claim!) everything went smoothly the first time.

All that to say, maybe don't ask about HOMEBIRTH, but just MIDWIVES. See if that helps, maybe? Hopeful for you!

Actually, according to them, my plan doesn't cover *any* midwives. I've been seeing (hospital) midwives thus far, and BC/BS had the nerve to say that though they didn't catch their error til now, I'll be responsible for repaying them for all those appts. Not doing it. No way. I can't tell you how much I hate them right now.

[MamaVolpe]

PPO. Their reason for the denial was that "my plan doesn't cover it." Not very specific. DH is going to call Human Resources tomorrow and also email me a copy of the EOC.

There are no in-network homebirth midwives under BC in my state. So I was hoping for an "in-network exception"... not to be told that I couldn't have a midwife at all. I did talk to a supervisor who told me the same thing. But they're so full of crap there that I know I'll have to do the research for myself.

Thanks for your help

They need to be more specific on the "Plan doesn't cover it" It meaning midwives, homebirth, what specificaly do they mean by IT? Even if they do not cover midwives in-network they can not refuse services from one out of the network. After all that is why you have a PPO.

Definatly check your EOC and if needed Appeal, Appeal, Appeal!

[lyttlewon]

Originally Posted by bygones75

Sounds like a good DH to me.

We can't do it if it's 6K... that's just beyond us. If she'll come down a few grand, I probably could. Trying to swallow my pride and get the courage to ask her.

I did buy lotto tickets today. I won $4. Ah well.

Yes ask her! Maybe if she understands you have to pay out of pocket that will make a difference. My MW has a sliding scale.