[Mama_of_1]

Hello Mamas! My DH and I have excellent insurance through his work. The company provides a self-funded plan with provider access through the BlueCross network in the Texas Gulf Coast region.

Our policy currently states that midwife and home births are a covered benefit. When I look up midwives under a 40 mile radius, there are four (4), non of which do homebirths nor are in private practice. Therefore, this automatically puts us in the Out of Network classification. Now, there is some coverage available through out of network benefits but it's not much. They will cover 80% of the "usual, reasonable, and customary." If any of you have read through your EOB statements recently, you know what a joke that reimbursement is.

Now, if we were to have a standard birth with an in-network OB/GYN in an in-network hospital, our cost would be $0. Yes, that's right, $0. The cost to the employer, would be significant, however, since my older son was born by cesarean, here that means that our baby would be born by cesarean. That's an additional cost to the employer in the range of $20,000-$30,000.

We have started with a midwife who we are very comfortable with and look forward to having in attendance at the birth of our daughter.

The reason for my post is to ask for your guidance in getting our midwife homebirth covered. Have any of you fought the insurance companies and won reimbursement? What techniques, wording, arguments, etc., did you use? I would appreciate some concrete input.

Thanks!

My apologies to the moderators if this is in the wrong category, I couldn't find a better match...

 

[nashvillemidwife]

Sorry I can't be more helpful, but wow! 80% coverage for out-of-network benefits is awesome!

Have you asked your midwife if she will accept in-network rates? You may be able to successfully petition BCBS to grant you an exception to cover her, but unless she signs a contact she is not obligated to accept their paltry rates as payment in full. If you are responsible for the balance, it may be a wash, or you may actually come out ahead if you just go with out out-of-network coverage.

Just something to think about.

 

[pjs]

I think since your policy is a self-insured policy (my DH has the same thing), I would try appealing to your HR director or someone who has the ability to make an exception. Clearly, a hb would be far cheaper than a hospital birth. Once someone in your DH's organization has the numbers in front of them, maybe they can approve an "alternative" treatment for you.

 

[dogmom327]

Quote:

Originally Posted by pjs I think since your policy is a self-insured policy (my DH has the same thing), I would try appealing to your HR director or someone who has the ability to make an exception. Clearly, a hb would be far cheaper than a hospital birth. Once someone in your DH's organization has the numbers in front of them, maybe they can approve an "alternative" treatment for you.

:

I don't have a link for you but I know there are mama's on here who've done that successfully.

Also, I've got to say, 80% for out of network is fantastic! In-network for us is covered at 90% and out of network is 50% with a $1000 deductible.

Something to consider, many midwives are good at creative billing to get a higher reimbursement rate and therefor recover their whole fee even at 80% reimbursement.

 

[Mama_of_1]

Quote:

Originally Posted by pjs I think since your policy is a self-insured policy (my DH has the same thing), I would try appealing to your HR director or someone who has the ability to make an exception. Clearly, a hb would be far cheaper than a hospital birth. Once someone in your DH's organization has the numbers in front of them, maybe they can approve an "alternative" treatment for you.

How would I go about finding comparable numbers? When my son was born nearly 10 years ago, the cost for his cesarean, as shown on my EOB at the time, was around $25,000. I'm not sure how much of that was paid versus written off, but that was 10 years ago! Sure, hospitals aren't just going to release their billing rates to someone that just calls up and inquires...?

Quote:

Originally Posted by dogmom327 : I don't have a link for you but I know there are mama's on here who've done that successfully. Also, I've got to say, 80% for out of network is fantastic! In-network for us is covered at 90% and out of network is 50% with a $1000 deductible. Something to consider, many midwives are good at creative billing to get a higher reimbursement rate and therefor recover their whole fee even at 80% reimbursement.

Oh, certainly, 80% coverage for out of network is wonderful, I'm well aware of how great our overall benefits coverage is. The point is that midwifery care and home births are a covered benefit under my DH's employer's plan. But, it's not available in my area! That's the problem - they're willing to cover something that isn't available due to geography, so how do I argue that?

 

[pjs]

I think given that many folks don't have any insurance these days, you COULD call up the hospital and ask. I know my ob has their fees for all sorts of standard things (including global maternity/delivery) hanging up in their office. You could just say you don't have insurance but make too much to qualify as low-income and could they give you a cash price for labor and delivery. My guess is where we are a vaginal delivery is probably close to 10-12 k once all is said and done, though I haven't had a hospital birth in 7 years.

I'd have DH broach the subject with HR and see what info they need so you can focus your efforts on the best way to get your hb covered.

ETA- there's a sticky in the hb forum about appealing for hb coverage, perhaps that might be helpful.

 

[heatherh]

I was in a similar situation. I'll PM you.

 

[rixafreeze]

Yeah, my IN-network is 80% and out-of-network is 60% so, frankly, consider yourself lucky. I have a friend planning an (in-network) hospital birth and it will cost her at least $3,000-4,000 out of pocket after her deductibles and copays. And that's if she has an uncomplicated vaginal birth. A c/s would be much higher with our insurance. But good luck getting it covered totally--I hope you can!

 

[murphysaangel]

I believe that there is some sort of insurance law that states that if your insurance does not have a specialist in-network within x amount of miles from you, they have to cover it in-network. So, technically they should have to cover your out-of-network homebirth midwife as if it were in-network unless they can provide you with another in-network alternative. And that should be based on the CODE of the procedure, not the type of specialist. Now, I am in NY but I am basing this on working with insurance companies with a chiropractic office for 5 years. We live on the border so we get both NY and NJ patients. This might be a federal law, or it might be state. I wish I had some sort of specific link or something to direct you to. But you could call your state insurance dept. and ask. I happen to have a union health plan, so they do not fall under these laws, but even so they do follow regulations like having to cover provieders that I see in an in-network hospital even if the actual provider (like anesthesiologist) does not accept my insurance. Just call your insurance, and keep calling. Ask for a manager on duty. And then call a few more times. They'll never give straight answers just once ;-)
good luck!

 

[larzanna]

i have BC/BS in ohio. I got my exemption becaue i told them that i could not find a MW that would do a homebirth that was in-network. I told them that i would be happy to use such a person if they could find me one.
I had to speak to the higher ups, ask for managers, and then their managers. But they eventually agreed that they could not find such a person, and made an out of network exemption.
It took hours on the phone, but i got my letter that i will submit with the claim to get reinbursed.
many insurance companies will make ONE out of network exemption (medical mutual does this too) but you have to really fight for it!

-L

 

[Mama_of_1]

Update: Called BC/BS. They do not have a designated geographic distance for in-network providers. They said that the kind of network that my DH's employer has setup, it's ALL considered in-network so they do not have out-of-network exceptions.

My next task: talk to the company's benefits line folks and find out more information on distance and in- vs. out-of-network coverage.

 

[heatherh]

I would also ask who the in network HOME birth midwives are. If there are any, you're SOL. But if they're really far away you might be able to work something from that angle.

 

[Mama_of_1]

The problem is that if they come up with an in-network homebirth midwife for me in, say Austin, that's a tad too far for me to reasonably drive. And, since they have no geographic distance limit to the policy, there's their exception.

I talked to a lady on the employer's benefits line, and she said that typically, they refer everyone directly to Premera BC. "But," I told her, "Premera isn't able to help me." So I asked her if there was anyone that could assist me at the employer's benefits office and she said that there is an appeal form available to use. They have a 2-step appeal process: 1) appeal to Premera BC at the start of services; if denied, 2) appeal to the Benefits office review board for coverage.

This is soooooo overwhelming. I am doing good not to break down crying at my desk... I know in the big scheme of things, no matter how our baby comes, as long as she's healthy that's all that matters, but having a home birth with a midwife is healthier for both of us. Why won't these folks understand?! ARGH!

The funny thing is when I was talking to the benefits lady, I told her that if I stay in-network, go through a regular ob/gyn and walk into a hospital, that's an automatic c-section with a (hypothetically) $30,000 bill, but if I birth at home with a midwife, it's $5000. Surely, since the plan is self-funded, they'd rather pay $5k instead of $30. She agreed but couldn't make the exception for me.

(sigh)

 

[heatherh]

One step at a time. Just.keep.bugging.them. There's still a good chance that there is nobody in network. Start there.

Is there an advocate on your DH's company's side? That's how I finally found someone at the ins co to contact who helped get my network exception.

 

[Mama_of_1]

I'll call the Premera BC line today and put the responsibility on them to find me a home birth midwife within a reasonable driving distance. I doubt they're going to match my midwife who comes to my house for all visits!

 

[deymm]

I'm in the same boat--insurance says they cover HB, but have no in-network providers and won't approve a gap exception to pay my MW in-network rates.

I'll be contacting my DH's HR dept next. I'll be watching to see what happens for you!

 

[Mama_of_1]

Update:
I called Premera again and this time got a lady on the phone that actually knew their network and how they process claims. More importantly, she was willing to listen to what I had to say. During this call, I was told that she could run the CPT codes right then and there if I was able to provide her with a billed charge. Sooooo, I took the main code, for maternal care (don't have it in front of me right now) and told her what the total sum was that my MW was charging as applied to that code. She sent it off to her supervisor while she had me on the phone and within seconds came back with a number that was their usual and customary that wasn't too horrid. That prompted me to run through the rest of the codes and she came back within a few more seconds with the reimbursement rates based on made up charges, just so I could get something to work with.

Ok, so I thought to myself, I can do this...

Then, after work on my way home, I called a lady that I had found out does insurance billing for some of the midwives in our area and had a nice long conversation with her. She said that one thing to watch out for is that often insurance companies have different reimbursement rates depending on whether the provider is in- vs. out-of-network. And, she also said that she would be willing to do the billing for an individual for a fee. The different reimbursement rates was something I hadn't thought of...

This billing lady also suggested going directly to a company-HR employee and asking for the exception at the start of the process rather than waiting until everything has been incurred and billed. Great idea, I thought! When I discussed it with my DH in the evening, he was quite adamant about waiting until we were ready to submit...

So, I begged him to please at least try to reach a live body to speak with...

:

That was about a week ago...

I will ask him again toward the end of this week.

 

[Mama_of_1]

Well, Mamas, it looks like this thread is now mute for me. My DH has just been informed that he's been laid off.

I'm still working but my insurance coverage is pretty basic and certainly doesn't cover homebirths or midwives or any combination of the two. Luckily, our next appointment with our midwife is tomorrow so I'll be able to hurry up and get any follow up bloodwork or testing right away and still have it covered but then that's it for us UNTIL! DH finds something fantastic and quickly.

 

[wombatclay]

Big hugs... I'm so sorry.

 

[Mama_of_1]

Thank you. We're pretty resilient and my DH laughed at me when I reminded him that I can be the queen of thrift when the need arises. I survived for years quite comfortably supporting myself and my son all by myself. We didn't have a lot of luxuries but we were comfortable and happy. My DH is used to a much more "instant gratification" life but he's been coming around.