GAP Coverage only for those with no Out of Network policy?

[GISDiva]

OK, I'm trying to take baby steps (ha!) here with my insurance company (happens to be United Health Care).

I called about getting In Network coverage for my homebirth midwife and was told by the very pleasant lady that Gap Coverage is only for those who don't have Out of Network provisions - which we do - so they will pay some for the service, just not as much. It's actually fairly decent (they pay 70% out of network vs. 90% in), but I think we still have to allow for the out of network deductible, which is 3000 vs. 1500. Or something. Insurance confuses me.

Anyhoo, has anyone else been told this? Do I take this as my final answer?

[alegna]

I think that's BS. I'm still working on mine, but I know there's at least one mom here who's gotten a gap exception to work with UHC.

-Angela

[nashvillemidwife]

It varies from policy to policy.

[shanniesue2]

I have united... and my MW's billing lady called the insurance company for me and they are covering my HB at In-Network rates and deductibles.

Just keep pushing them. Tell them that you would like an In Network exemption because there are no Midwives in your area that are in network. And if your MW is willing to work with the insurance company (some are and some aren't) try having your MW call (or your MW's billing person if she has one)

My MW LOVES united. She told me that in her experience, they have always been the most likely company to cover homebirth AND she says that she can frequently get them to cover waterbirth pool and supplies because her billing lady will send them information about haw waterbirth is effective pain management... so they basically cover it the same way they would an epidural or spinal block.

[Fly Girl]

Be careful when listening to the insurance company when it comes to how much they will pay for out of network. If your midwife would be in-network with your insurance company then your midwife and the ins. company would have a contract with an agreed upon amount for all of her charges. BUT if your midwife is out of network, then there is no contract for charges and the insurance will only pay what is usual and customary (which is a bogus random amount that they make up... and they won't tell you what that amount is). And then the 70% is applied from there.
For example, your midwife charges $3000 for prenatal and delivery. Your insurance thinks that a midwife should only be paid $1500 (the usual and customary fee). So 70% of 1500 is $1050. This is what the insurance will pay. You will be responsible for $1950. Not such a good deal.

But shanniesue2 is right about getting in network coverage. If UH is not contracted with any other midwives in your service area, then you should be able to get a Provider Gap Coverage for your MW. You just have to be very insistent. This will have to be preauthorized. And they should give you an authorization number. Make sure you get everything is writing. Good luck!

[khanni]

I just got a gap exception yesterday from UHC. I'm in CA, so I don't know if that makes a difference. One of the first people I talked to gave me the same spiel they gave you about the out-of-network coverage. I told him he was full of it and to give me the number I needed for the in-network exception. Finally I got the right number to call.

You have to speak to someone in Care Coordination. Once I finally got to this person (and it was hell getting there) it was as easy as pie. I was transferred about a billion times, just make sure you keep asking for care coordination.

[MamaVolpe]

If they are giving you out of network benefits then you don't have an HMO. And the previous poster is correct you need to speek with Care Coordination who does the auths for GAP coverage. When you go thru the voice prompter you should be able to say "Care Coordination" to get to that dept. If not then ask a rep to transfer you their. Don't bother explaining why just ask for that department. Most agents should transfer you. If you still cant get their dial 800-843-5429 press #2 for mbr and then #1 for care coordination.

[GISDiva]

Great tips, thanks everyone!!