Aetna Insurance and Sticker Shock Rant. - Mothering Forums

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#1 of 17 Old 02-14-2007, 03:04 AM - Thread Starter
 
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My last homebirth was covered 100% by Tricare Prime. My birth prior to that was a typical hospital birth. Also covered 100% by Tricare Prime.

At this point though, Dh is out of the military and we've got Aetna Choice Pos II as our insurance provider/plan. It's a high deductible plan. $2,200 deductible for in-network and $4,000 for out of network. After we meet our deductible the insurance will pick up 80% of the cost for in-network and 70% of the cost for out of network providers.

Each month we deposit money into a health savings account so that if we are ever caught in an emergency situation and need the $$ to pay for health-care, we'll have it available. Well, this last December we were involved in a fairly serious auto accident and our health savings fund has been depleted to the point where I'm fairly certain there is a whole 30 bucks left in the account. (The OTHER insurance for the person at fault will settle our claim once we are declared healed. However, at this point we don't have the extra funds to finish my rehab and I wonder -as a result- if we'll EVER get a document declaring a clean bill of health. So I can't just sit around and count on the settlement money. )

I only mention the auto accident because I feel a need to explain why we don't have those emergency reserves. :

(Not to mention we bought a house in January and are smack in the middle of moving/renovating)

About the same time that we all were recovering from the accident we found out we're expecting baby number three in September. Which is cool, surprising, and a bit unnerving all at once.

We've chosen to use the same midwife who worked with us during DD2's homebirth. Unfortunately, she is out of network for our insurance. In fact, after much googling I've realized that only ONE midwife in our area is in-network for our insurance and we'd made a decision a LONG time ago that we would not be using that birthing center. Not to mention that Midwife doesn't even offer Homebirths.

So really, ANYONE we choose will be out of network.

Which means a $4,000 deductible.

Which REALLY means we'll be paying pretty much ALL of this birth out of pocket.

And well, I'm having sticker shock. Seriously. I keep thinking, "why? Why? WHY?!"

I'm angry that virtually ANY medical OBGYN I could find in the phonebook would be covered in-network. But I only have ONE midwife (birthing center) option. I just checked the Aetna estimated cost for care website and for an UNcomplicated vaginal birth in my area they estimate cost will be $8,240. Assuming I pay $2,200 for my deductible AND the 20% copay the insurance company will STILL have to come out of pocket $4,820.

My Midwife bills $4,700 (I haven't talked to her about cash payment discounts, so let's assume this is the number we are running with.) Even if Aetna payed 100% of my midwife care they'd be saving themselves $120. Heck, if I was able to pay for her services as an in-network provider ($2,200 deductible and 20% copay) the insurance company would only pay $2,000 compared to nearly $5,000 for the hospital birth.

What's the deal?

Why the complete lack of compromise for midwifery care?

I cannot even begin to explain my frustration. And then my usually VERY supportive husband makes the off-handed comment "Tell me again what this would cost us if it was a HOSPITAL birth?" :

Urgh.

Who can blame him? I know he supports me and he's willing to dig down and do what it takes to make this homebirth work... I just feel angry that *I* am in a position where I have to ask my family to buckle down and sacrifice $5,000 of household money for this birth. I can't help feeling a bit selfish about it all and then I feel resentful because I am having THOSE feelings.

Then, I go back to feeling pissed that my insurance provider is so unyeilding regarding the whole in-network, out of network midwifery care. How can you SAY you support midwifery care when you make it abundantly clear that you really don't?
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#2 of 17 Old 02-14-2007, 01:18 PM
 
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Aetna is one of the insurance companies that has a strict NO HOMEBIRTH policy.

But, I have been paid by them twice.

I'm sorry, mama. It is so frustrating and it makes no sense re: the bottom line $$ for them.
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#3 of 17 Old 02-14-2007, 01:34 PM
 
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I have the same insurance plan as you do, and they are covering my midwife as in Network. (I am also planning a homebirth.) I got on the phone with them and complained about their lack of choices for providers (closest in-network midwife was about 90 mins away--no idea if she was hospital or home or both) and they added my midwife to their Network list. I would at least try to call them and see what they can do for you. Good luck.
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#4 of 17 Old 02-14-2007, 04:07 PM
 
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not to hijack, but I completely understand the absurdity of insurance companies. Chiropractic care costs much less for the patient and the insurance company in the long run (and often in the short run) yet they tend to have poor coverage...

I really hope you can work something out so you have the birth you want.

Prenatal/Pediatric Chiropractor (Diplomate) , raising the next generation drug-free!
DS - CJ :, the love of my life
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#5 of 17 Old 02-14-2007, 04:31 PM - Thread Starter
 
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I'm sorry, mama. It is so frustrating and it makes no sense re: the bottom line $$ for them.
This is what confuses me. If I were less adiment about my choice to homebirth I might end up "compromising" and having a hospital birth. Which, anyway you slice it would cost the insurance company MAJOR $$ compared to what they would pay for a homebirth. :
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#6 of 17 Old 02-14-2007, 04:34 PM - Thread Starter
 
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I have the same insurance plan as you do, and they are covering my midwife as in Network. (I am also planning a homebirth.) I got on the phone with them and complained about their lack of choices for providers (closest in-network midwife was about 90 mins away--no idea if she was hospital or home or both) and they added my midwife to their Network list. I would at least try to call them and see what they can do for you. Good luck.

The ONE midwife I can find on their list is actually closer to me than the midwife we are seeing. She (that particular midwife covered in network) does not offer homebirths and I am not comfortable using her for even a birthing center birth. Just a basic conflict in personal philosophies regarding birth.

Even still I find it downright appauling that only ONE midwife is offered as an option. How is that acceptable?

Do you know how hard it was to get your midwife listed as in-network? I need to talk to my midwife about it, but at least if they were in-network I would get SOME financial relief for this birth.
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#7 of 17 Old 02-14-2007, 11:27 PM
 
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I would at least attempt to get them listed in-network. Obviously, the closer MW doesn't offer the service you seek, and proximity isn't the only concern. You deserve more than one choice. I know for insurance I have had in the past, the literature has said that if your provider isn't in their network, you should request or petition to have them added - as though they want more providers in their network. Doesn't hurt to try, and could pay off.
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#8 of 17 Old 02-15-2007, 01:59 AM
 
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Before you go through the trouble of requesting an in network exception, find out if TX is a state that mandates insurance companies to pay for home birth-otherwise you may find out it won't be covered anyway. Aetna has a LONG UGLY history of not paying for home birth, and will ONLY do so if made to by state law.

Here's a possible reframe-you said in your original post that your midwife bill would be $4700. If you do an in net hospital birth, by the figures you present, you would be responsible for about $3400. Framed like this, your midwife would "only" cost $1300 over what you are likely to pay anyway.

Another possibility-is your midwife willing to unbundle? Ie, bill for prenatals while you only pay for the birth?

I get that coming from a place of 100% coverage to this is dizzying. Coming from the business end of it, I can say that 100% coverage is becoming a concept of such rarity as to deserve reverence and worship. For clients who pay cash (either because of no insurance or no maternity coverage), I'm shocked by the ones who are delighted that my fee is "only" $3000.

Best of luck, mama. And try to remember that aetna works for you.

Jennifer
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#9 of 17 Old 02-15-2007, 01:52 PM
 
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Originally Posted by Baby Hopes View Post
The ONE midwife I can find on their list is actually closer to me than the midwife we are seeing. She (that particular midwife covered in network) does not offer homebirths and I am not comfortable using her for even a birthing center birth. Just a basic conflict in personal philosophies regarding birth.

Even still I find it downright appauling that only ONE midwife is offered as an option. How is that acceptable?

Do you know how hard it was to get your midwife listed as in-network? I need to talk to my midwife about it, but at least if they were in-network I would get SOME financial relief for this birth.
I wouldn't be scared of Aetna, honestly--my experience with them here in Texas has not been bad at all! My midwife (CNM) does only homebirths (in Austin midwives are not allowed to deliver in hospitals), and she told me she has always been paid by Aetna. She didn't have the opinion that they were some horrible, awful insurance company either...other ones, yes, but not Aetna.

I agree with the poster above who said one available midwife is not a "choice." I really urge you to get on the phone with them talk to them reasonably. I was able to do it in a couple of phone calls, and my midwife helped me out where I got stuck so I could call them back and talk to them in their "insurance-speak." Make sure you get the names of whom you speak with.
I have the POS Choice II plan, just like you. Maybe other Aetna plans require a lot of haranguing to get things done, but mine really has been no problem.
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#10 of 17 Old 02-16-2007, 03:25 PM
 
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Just wanted to let you know that Aetna paid in the case of my recent HB. My MW didn't bill for the actualy birth, but for EVERYTHING up to and immediatly afterward. Aetna paid for it all. I am fortunate that my mw is licensed in another state, though. GA doesn't offer any licensing to hb mws. But I just wanted to chime in and let you know there is some hope.

Paige, mama to three girls, (10), (8) and (3)
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#11 of 17 Old 02-16-2007, 03:35 PM
 
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I'm not in any way defending the insurance companies (it will be a cold, dark day when I do that) but trying to figure out, from their point of view, why they would have these policies?

My thoughts (they are only guesses):

- They are afraid that homebirth / midwife care is so substandard and dangerous, that paying for that AND paying for hospital transfers would be more expensive than just paying the hospital for doing a "proper" job the first time?

- Or, taking the "substandard" and "dangerous" connotations out of the above idea, just plain thinking that X number of homebirths are transfers anyway, so overall would be more cost?

- Could they be sued, or afraid of being sued, if they reimbursed (which is effectively condoning, you know) midwife care and something goes wrong? Like, "I chose this midwife because you covered her, so I thought she was safe, and my baby died, I'm suing you!" ?

Any other thoughts?

I think it's worthwhile trying to figure out, because once we understand their real position, we can better respond to it.

Homeschooling mama to 6 year old DD.

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#12 of 17 Old 02-16-2007, 05:09 PM
 
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Call your insurance company and ask if the deductable applies to the facility claim and the provider claim. Some insurances applydeductables to the facility only, which means as you are having a homebirth there is not going to be a facility charge. Most insurances assume that you are going to deliver in a hospital or birth center so they quote the facility benefits for delivery, which don't apply to a homebirth. Ask them very specifically what the benefit is for your provider (midwife) and then what the benefit is for the hospital. You may see a difference that will suprise you in a good way.

Also call the one midwife in the network and ask her if she is booked yet for your delivery date. If she is than you can call in for an exception request stating that the only in network midwife in you area can't take new paitents with your delivery date and request that your provider be covered at the in network benefit level.

Good Luck

Livin' surf.gif Laughin' lol.gif Lovin' joy.gif - Just Me and Sammers, my homebirthin' little girl. 

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#13 of 17 Old 02-16-2007, 05:23 PM
 
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- Or, taking the "substandard" and "dangerous" connotations out of the above idea, just plain thinking that X number of homebirths are transfers anyway, so overall would be more cost?
True, I believe the homebirth transfer rate is well under 10%. But how many OB patients in a hospital are transferred to the operating room - more than 30%. OBs have a much worse "transfer rate" than homebirth midwives.

[/QUOTE]- Could they be sued, or afraid of being sued, if they reimbursed (which is effectively condoning, you know) midwife care and something goes wrong? Like, "I chose this midwife because you covered her, so I thought she was safe, and my baby died, I'm suing you!" ?
[/QUOTE]

The same could be said for OBs. OBs are reimbursed for their services by insurance companies every day.
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#14 of 17 Old 02-16-2007, 05:29 PM
 
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Aetna has covered all three of my homebirths including the labor tub for the last one.
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#15 of 17 Old 02-16-2007, 05:48 PM
 
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I'm not in any way defending the insurance companies (it will be a cold, dark day when I do that) but trying to figure out, from their point of view, why they would have these policies?

My thoughts (they are only guesses):

- They are afraid that homebirth / midwife care is so substandard and dangerous, that paying for that AND paying for hospital transfers would be more expensive than just paying the hospital for doing a "proper" job the first time?

- Or, taking the "substandard" and "dangerous" connotations out of the above idea, just plain thinking that X number of homebirths are transfers anyway, so overall would be more cost?

- Could they be sued, or afraid of being sued, if they reimbursed (which is effectively condoning, you know) midwife care and something goes wrong? Like, "I chose this midwife because you covered her, so I thought she was safe, and my baby died, I'm suing you!" ?

Any other thoughts?

I think it's worthwhile trying to figure out, because once we understand their real position, we can better respond to it.
Laohaire, your position gives much more credit to insurance companies than I would ever grant them. The bottom line of ANY (car, home, health) insurance company is to collect as much in premiums as possible and to pay out as little as possible. They are NOT social service organizations, they are for profit businesses. Taking a small example in the big picture, look at the number of insurance companies that only pay for home birth, or home birth midwives, or routine mammograms, or contraception WHEN MANDATED BY STATE LAW and not before.

And as to the discrimination against home birth and midwives-it's because gray haired eminences are making the rules.

I would like to see insurance leave the relationship I have with my clients. For many clients, when they add together their deductible, their copay, AND the amount of their premium, they are paying much more than if they just paid my cash rate.

Another take is those with no maternity benefits. They had the option when they signed on, but had to pay into it for up to two years before being able to use it. When they totaled that cost, it was much less expensive to pay out of pocket.

Those who are paying premiums, which may cost more than being a cash client, are in effect subsidizing the 30% c section rate, elective c sections, elective inductions, and epidurals that are going on out there.



Ok, rant over.



Jennifer
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#16 of 17 Old 02-16-2007, 06:12 PM
 
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it is true that there have been insurance companies sued in conjunction with suits against providers with no malpractice insurance. i think that is a big piece of it, the other being that many insurance companies have boards of physicians and that dictates bias.
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#17 of 17 Old 02-16-2007, 06:47 PM
 
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Laohaire, your position gives much more credit to insurance companies than I would ever grant them. The bottom line of ANY (car, home, health) insurance company is to collect as much in premiums as possible and to pay out as little as possible.
You're right, and each of my possible ideas addresses that directly. In all of my examples, the issue was that they would fear losing money.

Also, in case I wasn't clear enough in my first disclaimer, I wasn't saying the arguments I suggested were valid. I think whatever reasoning the insurance companies have probably ISN'T valid - but as I said, worthwhile trying to figure it out, since maybe we can address that reasoning head-on.

Homeschooling mama to 6 year old DD.

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