insurance in PA and getting coverage/reimbursement

thumbtack · Dec 6, 2010

Hi ladies! I don't post here often but I'm hoping you can help me.
 
I'm 13 weeks along and planning my first homebirth. <img alt="joy.gif" src="http://files.mothering.com/images/smilies/joy.gif">I'm very excited.
 
I'm having some trouble getting answers from my insurance company and I'm wondering if you all could help. There are a few causes for concern with regard to what I've been told.
 
1) I was told there is no way for them to tell whether they will cover a homebirth at all until the claim is submitted, because I have other options for delivery. However, the service I WANT is a homebirth. I'm worried because I've heard stories of people submitting after the birth instead of as they go, and it getting denied on that basis.
 
2) I've read that in some states, if you have maternity coverage your insurer must cover a homebirth, I thought I read that my state was one of those but now I can't find that information (I'm in PA).
 
3) There is an in network homebirth midwife thirty miles/an hour from me, so I don't know how the insurance rep can claim they may or may not cover homebirth (I have Health America, if anyone else here has had a homebirth covered by them I would love to know!). 
 
I don't think I can get a geographical exception although I think in this case I should be able to. The cut off for mileage is sixty miles <img alt="duh.gif" src="http://files.mothering.com/images/smilies/duh.gif"> Judging by my last birth in which the OB didn't even make it to the hospital in time, I'd much rather go "out of network" to have the only experienced homebirth midwife in my area, with whom I already have a relationship, attend my birth then sit and wait for an hour+ for the in network midwife to show up. Would they have a woman in labor drive an hour or two to get to a hospital or would they make an exception?
 
Anyway thanks in advance for any advice you can give me! The rep is trying to tell me that because of the contract with the hospital, homebirth doesn't wind up saving them any money. <img alt="eyesroll.gif" src="http://files.mothering.com/images/smilies/eyesroll.gif"> When I call today I have to point out the fee I'm paying is for everything and I highly doubt it's the same cost to them. And even if it were, then why not just agree to pay it if it's the same? I hate insurance.

ebegreen · Dec 6, 2010

I'll be interested to see responses to this. I'm kind of in the same boat, in PA, also planning to see a midwife for prenatal care and homebirth, this is our first baby. My midwife said she usually submits the claim to insurance after baby is born. I had no idea the insurance company could flat out deny it. I have BCBS and there is a homebirth midwife in that is in-network, who is over an hour from me, my midwife is about 20 minutes. 
 
I have been reading some about requesting pre-arranging cover from the insurance company. Maybe this would be helpful for you?
<a href="http://www.gentlebirth.org/archives/preApproval.html" target="_blank">http://www.gentlebirth.org/archives/preApproval.html</a>

thumbtack · Dec 6, 2010

When are you due? I've been going over her site! Lots of great information there! <img alt="thumb.gif" src="http://files.mothering.com/images/smilies/thumb.gif">
 
I don't know if I'll be able to get preapproval for the in network rate but even if I could get it for out of network, that would be something. I was told my midwife could call and ask for an exception.

butterfly1001 · Dec 6, 2010

I live in PA, I have Highmark BS, and my midwife works with someone who does billing for her, so she submits the claims for me. She has her biller contact the insurance company at the beginning to see what they cover. They will cover the services at out-of-network rates (they cover hospital, birth center or homebirth), so it would be 60/40, I would have to pay 40% coinsurance, after our deductible has been met. Well, we don't get sick often, so we NEVER get close the the deductible, so technically I would have to pay 100% of the midwife costs because the deductible is far more than her costs (although they pay for all our other labs, U/S's and everything at an in-network rate). But at DH's work, we have a Health Reimbursement Account that the company adds to every year that we can use to pay for coinsurance and deductibles. We have so much in the account right now that it's all being paid for, so I won't have to pay anything out of pocket.
 
From what I understand, depending on how your Health Plan is, IF they'd cover a homebirth, it could be subject to being paid at an out of network rate (I don't know of any HB midwives considered "in network"), after the deductible has been met. Obviously every insurance company is different, but that's how it may go for you. Hope that helps!

macandcheese · Dec 6, 2010

My kid isn't born yet, so I don't know the ending to this story ...
 
I am in PA and I have BCBS through my husband's employer. My MW told me that her clients generally have pretty good luck with them, though it might take some harassing on my part. She coached me to log all my calls, get names, record times, ask for supervisors, etc. 
 
A couple months ago (I was just past 20 weeks, I think?) I gathered all of my information as well as some statistics about homebirth costs/outcomes, and called. I said: "I'm pregnant and I would like to have an out-of-hospital birth with a certified nurse midwife. The only CNM in my area is not in your list of covered providers, so I need to know what to do in order to get prenatal and birth costs covered at the out-of-network rate." I didn't ask for anything—just told them what I wanted.
 
I was all geared up for a fight or something, but the person on the phone was just like, "Oh, okay ... let me get your information." She told me that the MW services would all be covered at the 80% OoN rate and that I didn't need to do anything as far as a preapproval—my MW could call to verify if we wanted, but that wasn't necessary. I'm supposed to just have everything submitted to BCBS after the baby is born.
 
So ... now I'm a few weeks away from my due date and I haven't done anything further. The 80% would be awesome (we paid the MW in full so long ago that we don't even miss the money, so any refund will be like a bonus), but now I'm wondering if I should push it at the last minute and try to get an exception. If BCBS covers any homebirth MWs, they should let me do gap coverage, I guess, since from what I can find there are none in their network near me.
 
Ebegreen, can I ask where you are located, or where that homebirth MW is located? If I do call BCBS again, maybe I could use her as evidence that they should actually provide coverage at 100% ....

thumbtack · Dec 6, 2010

Ok I just got off the phone with a supervisor, and I was told that home delivery is a benefit exception in maternity coverage, it's specifically written, unless it were medically neccesary. So, that is bad news most likely. She did tell me I can have my MW do an auth request, and I can appeal it when it's denied.
 
I was also told different services can be billed separately, since what I'm paying for is not just the delivery.
 
I was also told that PA is not one of those states that mandates insurance companies must pay for homebirth if the policy provides maternity care. I really really thought it was. I could swear I was looking at a map online, with all the states in blue and PA was one of them. Why I didn't bookmark it, I'll never know.
 
I'm paying my midwife the remaining balance this afternoon (we get a nice discount that way) so we do have the money set aside. It would really help us out to get something back.

thumbtack · Dec 6, 2010

macandcheese, I just noticed your location. I'm in the valley too.

macandcheese · Dec 6, 2010

<div class="quote-container">Quote:
<div class="quote-block">Originally Posted by thumbtack <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096510"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> macandcheese, I just noticed your location. I'm in the valley too.

</div>
</div>
 Hey, neighbor! Are you working with Laurice, by chance? If you are, Bill was super helpful in letting me know what to plan for when talking to the insurance people—he might be able to give you some pointers for dealing with Health America.

thumbtack · Dec 6, 2010

<div class="quote-container">Quote:
<div class="quote-block">Originally Posted by macandcheese <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096575"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> <div class="quote-container">Quote:
<div class="quote-block">Originally Posted by thumbtack <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096510"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> macandcheese, I just noticed your location. I'm in the valley too.

</div>
</div>
 Hey, neighbor! Are you working with Laurice, by chance? If you are, Bill was super helpful in letting me know what to plan for when talking to the insurance people—he might be able to give you some pointers for dealing with Health America.
</div>
</div>
 
Hi, yes I am excited to be working with Laurice! <img alt="joy.gif" src="http://files.mothering.com/images/smilies/joy.gif"> I used the paper Bill gave me "how to deal with your insurance company" when I made my calls, I'm going to be taking some notes when I talk to him today. I thought it might be a bad sign as far as reimbursement when he didn't seem too familiar with Health America and homebirth at my first appointment. But I will be doing this regardless of whether I get anything back or not, so I'm trying not to stress about it and just enjoy the excellent care I'm getting.

macandcheese · Dec 6, 2010

<div class="quote-container">Quote:
<div class="quote-block">Originally Posted by thumbtack <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096611"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> <div class="quote-container">Quote:
<div class="quote-block">Originally Posted by macandcheese <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096575"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> <div class="quote-container">Quote:
<div class="quote-block">Originally Posted by thumbtack <a href="/community/forum/thread/1283790/insurance-in-pa-and-getting-coverage-reimbursement#post_16096510"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a> macandcheese, I just noticed your location. I'm in the valley too.

</div>
</div>
 Hey, neighbor! Are you working with Laurice, by chance? If you are, Bill was super helpful in letting me know what to plan for when talking to the insurance people—he might be able to give you some pointers for dealing with Health America.
</div>
</div>
 
Hi, yes I am excited to be working with Laurice! <img alt="joy.gif" src="http://files.mothering.com/images/smilies/joy.gif"> I used the paper Bill gave me "how to deal with your insurance company" when I made my calls, I'm going to be taking some notes when I talk to him today. I thought it might be a bad sign as far as reimbursement when he didn't seem too familiar with Health America and homebirth at my first appointment. But I will be doing this regardless of whether I get anything back or not, so I'm trying not to stress about it and just enjoy the excellent care I'm getting.
</div>
</div>
 Yay! I have really enjoyed working with her. Hope your experience is great as well!

insurance in PA and getting coverage/reimbursement

thumbtack

Registered

ebegreen

Registered

thumbtack

Registered

butterfly1001

Registered

macandcheese

Registered

thumbtack

Registered

thumbtack

Registered

macandcheese

Registered

thumbtack

Registered

macandcheese

Registered