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Discussion Starter · #1 ·
I spoke with the office manager at the midwives office yesterday and was informed that the insurance will not cover ANY of the midwive's fees. They don't cover anything out of network. Needless to say, I am ticked because there is no one IN network that will do a homebirth.

I have Aetna insurance and live in Washington state. Has anyone had any luck with convincing their insurance to cover? Should I start writing letters? Making phone calls? Just submit the bill and see if they will cover any of it?

It is $2800. We will pay the midwives directly within the next few weeks, but I would love to get some of that back. Any BTDT advice. I haven't told dh yet and I don't think he is going to be too happy. Originally the midwives had told us that insurance should cover 60-80%. AARGH!
 

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I beleive federal law mandates that if there is not an "in network" provider, they have to cover another provider at out of network costs. So, if there is no in network BC or midwife, they have to cover someone for you. Not just another hospital. Maybe someone else knows more?
 

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I have aetna insurance and also have NO out of netweork coverage. MW said NO, Aetna said NO.

Don't give up.

keep calling, get a review, get a case manager, find a CNM that they do cover and argue that POV (that they do cover MWs just not one that specializes in normal birth) You do not have to say it is a HB because there is NO EXCLUSION.

it took me 5months and I had to get a reviewed twice but I did get 100% coverage with no upfront fees or even co-pays. Does your mw have someone who specializes in billing insurance companies? If not, find a MW that does.

What I finally did was make 100 calls until I convinced a covered GP (who was already in network) to recommend both me for HB and my mw for it.

It isn't easy, but you pay them to cover you in this situation. Giving up isn't an option.

Thats what I kept telling my mw every month when I was re-scheduling appts (I didn't see her until 20 weeks or so) that we'd just wait until we were approved because "no" wasn't an option. I'm paying more then $200/mo for this coverage and I'll be [email protected] if they are going to tell me no.

I was afriad to see an OB or CNM because I didn't want the insurance to then say I could simply continue my care with them (I had previously had a UP/UP so no professional care wasn't anything new for us). Another option is paying the mw per appt (usually $50, $200 for labs)

get names at each call
don't get emotional
do reach out to medical professionals in your community...find a MD/GP/GYN who is sympathetic *and* covered
do get your proof in order
do search out your local stats on:
cost of hosp. birth vs. homebirth, your city's C-sect rate and cost of c-sect in your community, your previous health records

Lt me know if you need more I will see if I can search out my legal papers and tell you exactly what our "exception" was called.

Carrie
 

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That's exactly my first angle, what Mysticmama said!
 

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Even though Aetna claims not to cover homebirth, they should still pay the unbundled prenatal and postpartum care, which are not technically homebirth services, even if provided in the home.

http://www.gentlebirth.org/archives/preApproval.html
http://www.insurance.wa.gov/publicat...ve_Health1.pdf Page 6
http://www.aetna.com/cpb/data/CPBA0329.html

http://www.mothering.com/discussions...d.php?t=455253
http://www.mana.org/laws/laws_wa.htm
http://www.seattlemidwifery.org/action_progress.htm

1996: Washington State implements an unprecedented law requiring all health insurers and HMOs whose home base is in WA to provide access to all categories of health care "willing providers" who are licensed or certified by the state, including CNMs.

(from gentle birth)
WARNING!!! If you have Aetna health insurance, you may want to change at the next opportunity, when your employer has their annual "open enrollment". Aetna doesn't cover homebirth, citing a single study based in rural Australia which shows that high-risk births far away from a hospital are high risk. They further cite the policies of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, both business competitors to homebirth providers. Their policy statement ignores a mountain of evidence that homebirth is as safe as or safer than hospital birth for normal, healthy pregnancies.. If their policymakers have any integrity, this logic will soon lead to cessation of coverage for planned VBAC's . . . there's no dearth of studies and AAP and ACOG policies proclaiming the danger of VBAC's . . . and then they'll stop coverage for any woman who declines standard ACOG/AAP recommendations regarding routine ultrasound, routine induction, routine IV's, routine use of continuous electronic fetal monitoring, routine administration of antibiotics for all GBS positive women (up to 40% of birthing women), and prompt cesareans for any woman who fails to progress in a timely fashion during labor and pushing. They may also stop coverage for children who are not vaccinated according to the full schedule of vaccinations recommended by the AAP, even though many intelligent parents decline the newborn hepatitis B vaccine and practice selective vaccination according to their child's own needs.

If this is troubling to you, as it should be, let them know. You can easily send e-mail to Aetna's National Media Relations Contacts and simply tell them that they should not be in the business of denying coverage for reasonable healthcare choices, such as homebirth, waterbirth and VBAC. They will especially want to know if you are choosing another healthcare provider because of this unreasonable policy. You might also suggest that they expand their research beyond ACOG and AAP recommendations.

Maternity Benefits Congenital Anomalies (Prenatal Testing) Mandated Group Offering RCW 48.46.375 WAC 246-680-020 The plan must cover prenatal testing for congenital disorders if it covers maternity 1. Carrier must determine medial necessity using the standards as set for by the Board of Health 2. Carrier may determine medical necessity on case by case basis if partner is carrier of genetic disease 3. Carrier may not impose restrictions which limit review for services to medical director determination only Contract Pg._______ Comments: Direct Access to Services WAC 284-43-250 Does the contract impose notification or prior authorization for receiving women's health care services unfairly: 1. Carrier may not impose a limitation on maternity services that would require all child birth to occur in a hospital 2. Carrier may not impose requirement which requires a physician to conduct a delivery 3. Carrier must cover medically necessary supplies of a home birth Contract Pg._______ Comments: Length of Stay Managed care Mandate RCW 48.43.115 ERIN Act PSHA 2704 Does the contract allow the health care provider in consultation with the mother to make decisions regarding care and length of stay in a hospital? 1. If length of stay guideline is stated must be no less than: 48-hour normal birth/96-hour caesarian section birth 2. The contract can not restrict follow-up care when ordered by the attending provider in consultation with the mother 3. The Carrier must provide notice to policyholders regarding this coverage yearly by January 1St . Contract Pg._______ Comments: Pregnancy PHSA 2701(d)(3) For group contracts there can be no pre-existing condition exclusion for pregnancy, no matter when pregnancy began and whether medical advice, diagnosis, care or treatment was recommended or received for the pregnancy. This contract may not contain a pre-existing exclusion for pregnancy even if the previous health plan did not cover pregnancy. Contract Pg._______ Comments:
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Pregnancy Discrimination Title VII of the Civil Rights Act EEOC Compliance Manual A plan may not unreasonably discriminate against pregnant women. Unreasonable discrimination includes: 1. Restricting travel during pregnancy including the 3rd trimester 2. Charging higher premium for care Contract Pg._______ Comments: Unfair Practices RCW 49.60.040(3) WAC 162-30-020 If the group contract is being sold to an employer who directly or indirectly employs either eight or more persons, does it include full health insurance

(from:http://www.insurance.wa.gov/publicat...HMO_1-1-03.pdf) Page 11

Aetna says they do not cover homebirths except for when required by law. Well, washington law says they cannot mandate that all birth occur in a hospital or be attended by a physician. So, if there is no "in network" midwife to attend your birth OUTSIDE of the hospital, it stands to reason that they have to cover this midwife at least at out of network rates. Good luck.
 

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I am a midwife in a state where midwives are not licensed.

I had a client with Aetna insurance that offered no reimbursement for out of network services.

She made it pretty far in the process of getting a waiver for in-network coverage. What they asked her to do was have her family physician write a referral for my services. Her doc did this happily and everything seemed to be going swimmingly until someone decided that because Michigan was not a state that licensed midwives that they would not cover my services.

This is the approach I would take -- it doesn't matter where you are having the baby -- if the provider is out of network, sounds like you won't have any coverage. You should see if you can get a waiver for in-network coverage.
 

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I just had my baby this past January, BTW.

I saw that stuff on GB when I was working on it, but I didn't let that stop me.

we have PPO and get NO out of network coverage, but my CPM was paid in full with thie waiver.

I had an u/s (by choice, covered) but declined everything else and did not have a problem.
 

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Aetna! Yes! Keep trying! They scoffed at us when we asked directly if they would cover a midwife-attended birth. They even said no to coverage for an in-hospital CNM birth! Now, nine months later, whaddya know, they're paying at least 67% of the fees for my homebirth. From what I have heard Aetna is NOTORIOUS for this. Don't give up until you've billed them!!
 

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Discussion Starter · #9 ·
Thank you everyone! I appreciate all of the links mysticmamma. I'm going to print out this thread and keep it for reference.

I guess I will wait until the baby comes, attempt to bill Aetna and then continue with the appeals process after they have denied payment. Does that sound like the best course of action?

I have no desire to change care providers at 30 weeks pregnant, I really like the midwives I am using. And I know that Aetna does not have anyone in network that will do a homebirth. So I don't see any other options.
 
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