Well, it seems as though this battle has come to an end for me. I contacted the attorney general's office and they were lovely, however, the original decision to deny in-network coverage for my out-of-network midwife is being upheld. Even though an in-network home birth midwife does not exist, the explanation for denial remained that it was "contractual."
From the attorney general's office: "The response states that since your City of New York plan has out-of-network benefits, the contract language does not allow for any other method of reimbursement, like an in-netword exception, for a non-participating provider like your midwife. The response goes on to that your benefit was reduced by your plan's $1500 deductible for catastrophic coverage (which includes maternity services) and a $200 basic medical coverage." They then go on to recommend that I contact my midwife directly to "negotiate a reduction." This is a PPO plan, and according to the attorney general's office, if I had a more restricted plan such as an HMO that does not actually offer out-of-network benefits I would be able to get an exception made. So that's that. Make sure you read the fine print of your insurance contracts, ladies! That catastrophic "benefit" is a killer. If anyone has the same GHI plan (New York City Comprehensive Benefits Program, NYC/CBP. PPO plan) and has had a different outcome, please let me know! Thanks and good luck to everyone!
We have GHI - PPO plan (my DH is a NYC teacher) and i didnt even SPEAK to, e-mail, or in any way contact my ins. co before I had my last HB (8/21/2010) - i live in Nassau Cty - used Gaia Midwifery and their biller took care of everything.....i was always told that New York State has assured me the birth of my choice - if i want a HB, but no CNM's near me take my insurance, my insurance will still cover them as if they were an IN NETWORK provider. MY HB cost $600 - that was a fee from the MW - which i think had more to do with her on-call fee than anything else. Everything else was paid for - no questions asked. I think having a competent biller at the MW group helps SO MUCH! I have never heard of a 'catastrophic benefit' and ive had two family members hospitalized in the last 3 years - if that wasnt a catastrophy - i dont know what is!
I wish i could be of more help - it certainly sounds like you have fought this battle well - im sorry it didnt end in your favor!!
Happy at Home Mama to DD 4/95 DS 4/98 and DS#2 8/10
motherhendoula - that's so awesome!
I am a nyc teacher and having the same problem as caroline0617 with ghi. my midwife even has her own billing person who said that once the insurance company answers that they have out-of-network benefits, there's literally nothing that can be done.
I'm wondering if this is something they started fairly recently to get out of paying for so many homebirths... even my midwife said she's had a lot of nyc teachers in the past with ghi who had no issues. seems like they're just out to get us now =(
sorry for the late reply
the AG office is very helpful but in my case it did not work since i found out my plan is sitused in DC not in NY
see this other thread for details
Good luck, cigna was really bad with me but it all depend on your plan