Anthem BCBS Coverage? - Mothering Forums

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#1 of 6 Old 08-06-2012, 11:17 AM - Thread Starter
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So, my hubby and I recently found out we're expecting, and I've always wanted a midwife instead of a dr. I was trying find one in our network so we wouldn't have to deal with drama over insurance, but the one covered in our area (eastern VA), is in a huge practice with 5 other doctors and they told me when I got to the appointment (they should have over the phone in my opinion) that I *will* see all the doctors and they have no idea who will deliver (I don't even think an effort is made to have your preferred one deliver) I am looking into other midwives in the area, and if we're going that rout, I'd love a home birth.


I was wondering if anyone knows how to get the process started/any tips or certain things I need to do.


I called today to ask if a home birth is covered and since it's not mentioned specifically in our plan (A PPO I think) the lady was going to check with my hubby's employment company to see if it was covered and she's supposed to call me back by 5 on Wednesday.


Any help would be great!

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#2 of 6 Old 08-07-2012, 11:20 AM
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hi!  we have anthem and have had some success with getting coverage (they will cover for us but are severely underpaying).  I would call them and see if they cover the procedure of a homebirth.  If they do, that gives you a good foot to stand on.  If the midwife you want to work with is not in network, i would ask to get an in network exception to have her covered since she is the only provider in your area that provides this covered service.  Keep all paperwork and keep track of who you talk to and what they say.  Once you are able to get the in network exception (do this as  early in your pregnancy as possible) you will be stress free until after the baby is born (if your MW bills global fee, like ours did).  Also, see if your MW works with a biller, this can make everything easier in the end.  Good luck!

Two semi-crunchy mommas in Indy taking every day as it comes!  Baby #1 born 1/14/12 at home!



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#3 of 6 Old 08-07-2012, 12:07 PM
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We have Anthem BCBS high PPO and used 2 midwives with them (different pregnancies.) We live in Florida which has laws that make the insurance cover out of network as in network if there is no network provider within 30 miles. Our insurance is through DH's head office in Ohio though.


Pregnancy 1

Licensed Midwife (direct entry) we just went with the out of network $500 deductible and 70% coverage as we didn't know about the in network stuff. We ended up a hospital transfer & c/s after my labor went past the time limit for a LM with broken waters (long story & legal issue transfer rather than medical) we had already paid $1600 (our share of the $4500 fee) then the insurance paid the full $4500 to the midwife according to the statements we got months later. (In network would have been 100% coverage) and we only had a $250 copay for the entire hospital side.


Pregnancy 2

Certified Nurse Midwife that we got permission to use as if in network. Her fee was $4600. She was the only provider we could get to do a home VBAC, so getting permission for coverage was not too bad. However when it came time to pay her the insurance kept claiming things as NOT COVERED in network. We ended up paying the shortfall (The midwife did her job and deserves the full fee) which ended up being nearly $1800, so getting the exception actually cost us more than just processing as out of network. Our CNM used a billing company AND did global billing and they tried as hard as they could to get as much out of the insurance company as possible.


The only positive is that all that extra money we had to pay will now be a tax deduction thanks to the Affordable Care Act, so we'll get some of it back on our tax refund.


It is infuriating when having the HBAC SAVED the insurance over $30,000, as going to the hospital (therefore staying with a network provider) would have been an automatic c/s as our local hospitals all have VBAC Bans in place, and our 1st c/s cost over $35,000 just for me and another couple of $1000 for DS1.


I have read here of other people getting the 100% coverage, so hopefully you'll get better coverage than we did.

Lynslingboy.gif, wife to Robtrekkie.gif & Mamma to angel.gif "Moredcai" 12wks July 09, Aiden(6/1/10)banana.gif and Seth(9/7/11)babyf.gif hbac.gif  New blessing Megan(5/9/13)hearts.gifuc.jpg

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#4 of 6 Old 08-07-2012, 06:58 PM
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When my first son was born, I had an Anthem BCBS PPO in VA (and it's different for every state, btw, as well as different..uhm...kinds of Anthem? or other plans? or whatever). I had a homebirth, and Anthem basically refused to cover it because they said that there were in-network people who could have done it. My midwife, a CPM, was not in-network. NOR WERE ANY OTHER HOMEBIRTH PROVIDERS IN A 100 MILE RADIUS. I called to contest this, and they said that they have a boatload of OBs in-network, and that birth is birth, and homebirth doesn't count as a different kind of service. I'm still unbelievably pissed about this, but, as my sweet and supportive husband says, we had a wonderful birth and a healthy baby. It's really priceless, frankly. 


YMMV, I think it really depends on the person who reviews your claim. I agree with the previous poster that you should TRY to get an out-of-network exemption. 


Now I'm with Aetna, for baby #2, and my mw (the same CPM) says she's had better luck with Aetna...but...we'll see. I basically did my budgeting for this year under the assumption that it would not be covered; if I get money at the end, then that's a welcome surprise. 


One other thing to keep in mind is that, if your employer has a flex spending account, you can use those dollars to pay a midwife. This makes them pre-tax dollars. So, if you're in the 10% tax bracket, it's like a 10% discount on your midwifery care.

Mama to Silas Anansi, born 9/9/10 and Petra Eadaion, born 10/1/12.

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#5 of 6 Old 08-09-2012, 10:26 PM
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We have BCBS of OK and I went ROUNDS with them when I wanted to have midwifery care instead of an OB.  The stated over and over they would not cover midwifery.  There was LOTS of tears and perhaps some yelling (pregnancy hormones, I couldn't help it!)  smile.gif  In the end I decided to pay the home birth fee out of pocket (about $4000) and submit it to my cafeteria plan for reimbursement.  In the end we decided to go with a CNM and her billing service decided to submit it to BCBS just to see what would happen.  They ended up paying about $1200 of the fee because she was a CNM and not a CPM.  It was a nice surprise after we had already decided to pay the fee up front.  We had decided to just pay full cost because after my first birth (a very unplanned C-section and subsequent uterine infection from debris left behind after the c-section) we paid almost $6000 in medical fees after insurance covered the 90%.  


It really stinks that we have to fight for this!!!  

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#6 of 6 Old 08-12-2012, 12:19 AM
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We fought like crazy over our first HB with Anthem PPO, and are now fighting again...  Since the rules are different in every state, I'm not much help, but am chiming in to say:

1) itemize your bill, don't do global.  At least for us in CA, after multiple phone calls trying to get more money the first time around, I got one woman at Customer Service who told me on the sly that they don't put Global and Surgery in two different fields; that is, they reimburse "usual and customary" the exact same amount whether the code says global services or just the birth itself.  They counted customary as something like $1800 (ha!), and reimbursed us 40% of that after our deductible.  When I resubmitted an itemized bill for pre- and post-natals, I was able to get back a few hundred more.

2) Don't ask whether home birth is covered, ask whether midwifery services for out of hospital birth are covered.  Most insurers won't cover home birth supplies (like birth kits, etc.) and won't pay a facility fee for home births (natch, since there's no facility) but I've found that many at customer service interrupt that as "home birth isn't covered."  This is what I'm dealing with now - someone at Customer Service told me home birth is not covered in my plan, when in fact the plan says NOTHING about home births at all...but now that it's in my file that she told me that, I have to fight to get that reinterpreted/removed, despite the fact they covered it as out-of-network just 2 years ago...If they cover a midwife for out of hospital (usually a CNM if they're picky), they should cover her services for home birth since in theory you could have been intending to go to a birth center or what have you.  At least it gives you a leg to argue on, whereas asking about "home birth" flags you as wanting a facility fee.

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