Attn: Homebirth Mamas with Tricare

[Mothra]

I'm currently 25 weeks pregnant, give or take, with my third and am planning my first homebirth. Dealing with Tricare has been a nightmare, to say the least. I finally got a straight answer, I think, and here is what I'm dealing with-- they will pay $900 for a midwife's global pregnancy fee in my area. That is to include prenatal care, delivery, and post partum care AND the six week check-up. That is their maximum allowable charge, and by law the midwives cannot charge more than 15% above that fee. Ridiculous, right? Well, the midwives do charge more, who could blame them, and the going rate around here, Central Coast California, is about $3500.

They claim to offer home birth as an option, but yet they expect midwives to take a substantial cut in their fee or expect beneficiaries to suck up $2700. My husband and I are dedicated to doing this no matter what, so we will have to beg, borrow, and steal the money to pay for the homebirth. Fortunately, we have parents and siblings who can help us out and we can pay them back with our tax return, but this still is a huge financial burden for us. My husband is only an E-5. Most lower enlisted cannot afford this at all.

(For those who don't know, Tricare Prime, the plan available to active duty family members, is full-coverage. No co-pays for in-network treatment. The $900 is all that is available to CNM's who are in-network. Out-of-network, they only pay about $300.)

I'm curious about homebirth coverage in other Tricare regions. Has anyone gotten any real money out of them for this? What is the going rate for a homebirth, attended by a CNM or CPM (if that is comprable to a CNM in your state), and how much did Tricare cover?

I'm going to do what I can to address this with Tricare. I have phone numbers, e-mail, and snail mail addresses for the main offices, but I want to get as much information as possible. Looking this stuff up online is tedious and unproductive, and I cannot get anyone on the phone who knows what they are talking about. (Everyone wants to know why I don't just go to the hospital.) I want Tricare to realize how much money they would save if they would just pay midwives a reasonable fee. They pay $800 for an epidural at the hospital where I would deliver!

[kama'aina mama]

Those are some really low numbers! I was reimbursed $1000 after paying my midwife $1600. I don't know that I have any useful advice except just keep hammering away at them. Make an appt with a Tricare rep. Sit down and crunch teh numbers. Be certain there isn't a higher payout of you are Tricare Standard (unlikely but not unheard of) make sure that figure isn't just for delivery and that it does include all your prenatal. Ask about regional cost offsets. I dunno... and the just keep submitting bills!

[Mothra]

Where are you? $1600 is fantastic! I talked to a Tricare rep at the office here yesterday, and she told me that the payout for Prime, for the global fee for pregnancy and delivery, for a midwife is only about $900 in this region. The payout for Standard is actually 20% less because of the 20% co-pay. Two of the midwife practices I've spoken with here have taken mercy on me and offered me the cash discount, about 15%, and one will pro-rate my bill if I go with her because they feel sorry for me, I guess.

I'm definitely going to bug them until they just can't take it anymore. When I went to the local office yesterday, they already knew who I was. The people from the regional office called them every time I called in with a question.

[EmmaJean]

I can't give you any advice bc I haven't been there...YET!!! I expect to have at least one tricare baby in my lifetime. DH goes active duty again in a couple years.

ANYWAY, this whole situation sounds a lot like what my dad deals with medicaid. He's a dentist, and it's amazing how LOW the payouts are for medicaid. So if he does a treatment that costs $50, medicaid pays him back $20, and he has to suck up the rest--write it off in taxes, I guess. I would think that your mw's would be familiar with the system since they are a tricare provider. Wouldn't they know they're going to have to suck up some of the cost since you're a tricare mom? Well, it sounds like you have a very caring mw to adjust payments for you. AND family to help you out! I know it'll all work out--what a pain to be stressed by this right now...

[kama'aina mama]

$1600 was in VA beach.... aka tricare mid-atlantic.

[Mothra]

The midwives actually still charge the full fee. The lowest fee, with the one that will pro-rate, is $2400 and I still have to come up with it at least a month before the due date. They just can't afford to eat the difference. There is only one midwife in the area that is actually contracted by Tricare, but she told me that she is planning to sever the contract because she can't accept the fee they offer. By law, they are only allowed to charge 15% above the maximum allowable, but if they are not contracted, then I can bill Tricare myself as long as the midwife is a CNM, not an LM.

I found out that the payout for obstetricians is only $1600, so that doesn't give me a lot of ammo. I might be able to get about $1300 out of Tricare according to one claims specialist I talked to, but probably not the full amount because I'm so late in my pregnancy. Where Tricare really saves money is on the hospitalization and anesthesia, but they don't consider that because they are only looking at provider fees.

So we're dealing with all of this and the possibility of my husband being put out of the military on a medical discharge, so we still don't know what we are going to do. I really, really want this homebirth, but if he is going to be put out of the military, with a low disability rating, we might not be able to afford it at all.

We'll see.

[EmmaJean]

So sorry for your stressful situation. I can't believe the payout for docs is only $1600. So families have to come up with the other thousands of dollars? Sounds like a regular HMO!:

Doesn't a medical discharge take a long time, especially if you want it to, KWIM?? Oh, your situation sounds so complicated. I hope you find some peace in all of this. Soon.

[Mothra]

The obs all accept Tricare as full payment. Think about it, they only spend five minutes with you once a month, they don't even see you until 12 weeks or so, and then they spend a few hours delivering the baby. C-sections pays them a lot, too, and the c-section rate around here is well over 40% because the local hospital does not "allow" VBACs. They can afford to suck up the rest because they have 15 or so patients delivering a month. The midwives around here only take on 3-5 patients a month.

A medical discharge does typically take a long time, up to a year in some cases, but we have to save some money if we're going to be back in the civilian world. I think we're going to do the homebirth regardless, though.

Edited to thank everyone who has replied. If anyone else has any more info, I would love to hear it.

[JayGee]

My DH is ADAF and I'm "thinking about" a homebirth this time. Tricare won't pay a thing because homebirthing with a midwife is illegal in Illinois. Her charge is less than yours though, $1500 for all prenatal care, the deliver, and 6 weeks of postpartum care including care for the baby. I'm going to pay out of pocket if we do homebirth.

[Mothra]

That is so ridiculous.

Just out of curiousity, what do you do in the rare event that you need to transfer to the hospital? I guess the midwife doesn't go with and you say you were doing a UC? Those are legal in every state, right?

I'm still going to pay more out-of-pocket than you. This area is just stupid expensive. Met with another midwife today who charges $1600. I can't believe that Tricare coverage is pretty much the same region-to-region without regard to how much healthcare actually costs.

[Mothra]

I meant to say $3600. She charges $3600.

[EmmaJean]

mothra, giving birth unattended isn't against any laws. If the baby needs to go to the hospital right after or something, the parents could be charged with something, but the birth itself isn't illegal. The UC experts here coule tell you more!

[kama'aina mama]

Many MW's will go with you to the hospital as a doula.

[mamachiquita]

OK, this is really weird, this is the exact thread that I needed to see. I am three weeks pregnant right now, my husband is Active duty Air Force, and I am adamnant about having a homebirth with a midwife. I talked to the clinic yesterday and they gave me a list of providers that Tricare will pay for in this area, and they are all OB/GYNS, no midwives. Now I am freaking out because I feel like we will have to foot the bill for the entire process. My husband is an E-5 as well, so we aren't rolling in money so I would really like to have some help with the payment. I'm going to be calling midwives in my area on Monday to see if any of them have dealt with Tricare or will accept it at all. I guess my question would be... would it be smarter to go to Tricare first and basically beg them to pay for a midwife, or would it be better to just hire the midwife and hope that Tricare accepts the claim? This is all new to me, so please don't laugh if this sounds stupid. I didn't sleep at all last night worrying about this. I am getting to the point where if worse comes to worse, I will go with their silly recommended provider for prenatals and then "oops" not make it to the hospital in time to give birth (we live over 30 mins. away anyway). However, I would much rather have the expertise of a midwife with me at birth in case anything goes wrong. Any advice would be appreciated!!

[JayGee]

Silly, isn't it? The midwife I'm considering will transfer with you to the hospital and say she is your doula . This particular MW has delivered over 1800 babies and has had NO fetal deaths. Better than most hospitals, IMO.

I sure hope you can have the birth you want. My very medical first birth was in a AF hospital. I never want to go that route again . Right now it's just a matte of talking my Dh into homebirthing.

Kristina

[Mothra]

Mamachiquita-- get an ob referral and then start calling midwives in your area. You can get a referral to any obstetrician in your town, and once you have it you can transfer with no problems. I did it four times, and am getting ready to do it again. You can see any CNM you want and Tricare will reimburse you their standard maximum allowable charge, regardless of whether or not the midwife actually accepts Tricare. She will have to be willing to fill out some paperwork for you, but it will be considered out-of-network. Your midwife has to be a CNM, cannot be lay midwife.

My advice is to call a claims specialist and ask him or her exactly how to do this and try to find out how much you will get back. The billing code in my area is 59400-- obstetric care from provider other than MD, or something like that. They can punch in that code and tell you how much you will get back. If the first person you talk to doesn't know what they are talking about, call back and talk to someone else. Where do you live? I talked to someone wonderful in the Golden Gate region, Northern California. Be sure to stop someone if they start talking about Point of Service options. That is NOT what you want. Make sure you talk to the authorization people and find out how to go about getting your referral changed to the midwife.

Good luck. Feel free to ask anymore questions. I might not be able to help you, but I can try, and maybe someone else would know.

[mamachiquita]

Thank you so much, Mothra, for your quick and extensive reply. I honestly feel so much better now that it seems like a much simpler process than I thought it would be. So, If I understand correctly, I should let them give me the OB referral and then request a switch to a CNM? Should I actually visit this OB for 1 or 2 appointments or should I just switch before I even visit? I feel like such a newbie at this. At our last base, we just had OB care on base and then I birthed in the military hospital. Of course, that was a complete nightmare, but at least I didn't have to deal with all of this referral crap!! We live in Tucson, so we may be under a different region than central CA. I think I will just go in personally to the Tricare office on base and explain my situation, what do you think? Or is it always more effective to deal with the headquarters directly?? Sorry for the dumb, probably obvious questions. Any advice is much appreciated, though! Thanks!