This post is the fourth in a series I hope to complete before the arrival of my second child, who I plan to birth in our home under the care of a midwife in the coming weeks. You can find the whole series of posts collected here on this page.
The short story here is that I interviewed and developed an instant respect and fondness for my midwife before I began seriously exploring the extent of my health insurance coverage for midwifery care. I ultimately learned that I had no coverage, and I spent greater than two months running through an infuriating gauntlet of insurance red tape in pursuit of some measure of coverage for my home birth. This will probably be a rather boring, tedious post to read, honestly.
The longer story is this: After discussing with my midwife the fee for her care, some quick mental math told me that I’d likely be paying close to what I paid for my previous hospital birth. My midwife charges a sliding scale fee of $2500 – $2900 (you determine where you wish to pay in that range). With my first pregnancy, my OB charged $900 for the term of my prenatal care, and the hospital bill from Arlo’s birth was $1600. (The sum of these two costs doesn’t include the various co-pays and bills for labs and such that are a part of general prenatal care.) The expense for a home birth, I quickly concluded, was pretty much on par with my out-of-pocket responsibility for a hospital birth. I figured we’d just roll with the expense as we did the first time.
But, you know? There are many differences between my current pregnancy and my previous one, and among them is a pretty critical one: our family’s income level. It was notably easier to absorb the expense of my first pregnancy when we were both working outside of the home. But now, as a single-income family, we have to be considerably more mindful of how we spend our money. There really is little room for unnecessary spending. After many conversations with other home birth mamas, I learned that some of them were able to get partial reimbursement for their births, and a seed was planted. Any amount of money that we might be able to save ourselves would be worth the effort, I figured, no matter the hassle. Further, we pay for our health insurance, and we should do our best to make it work for us, rather than against us. Midwifery care is as valuable, substantial, and worthy of insurance coverage as obstetrical care is, and not trying to secure some coverage seemed like I was, I don’t know, conceding that this type of care is inferior to obstetrical/hospital-based maternity care.
My midwife contracts with a billing service specifically trained and experienced in billing for midwifery care; I paid $15 for them to check my policy and interface with my insurance company regarding coverage. Their role reminded me much of the financial counselor at our former infertility clinic who helped us sift through our policy for infertility treatment coverage. The infertility clinic and the billing service both gave answers that were the disappointing same: no coverage. I swallowed a lump in my throat as I read the notes on my Verification of Benefits document from the billing service: Midwives are not covered. In-network exception is not possible; home birth and midwives are not covered.
At this point, I reached out to N’s point of contact for his human resources department at work and started a dialogue with her about this lack of coverage. I wasn’t sure where this effort would take me, but I figured that she likely had worked with other families who may have experienced network gaps. I wish I could say that this exercise was helpful. It was not.
The HR staff person was receptive and eager to assist; she contacted her counterpart at the insurance company to see if this individual could also help suss out the details. That insurance person (who helps N’s company structure their policy every year) repeatedly provided incorrect guidance over the course of several weeks. (No, this was what we needed to do next. No, wait, it’s actually this. I’m sorry, I was mistaken. Your next step should be this.) Perhaps this repeatedly wrong guidance isn’t the insurance person’s fault; perhaps this just serves to illustrate how fucking insanely cumbersome and confusing it is to navigate insurance policy.
With each new piece of instruction, I would contact the care coordination department of my insurance’s member benefits office. I would tell the care coordination person what I had been advised by their very own personnel–their personnel implicit in formulating our current policy–and the care coordination staff would contradict the information I’d been provided. Lather, rinse, repeat.
Because there were no midwives covered within a 30 mile radius of St. Louis (how is that even possible????), I was eligible to request an exception that my midwife be considered in-network for our policy. At first I was told that my midwife’s billing service could do this on my behalf. They tried, but were told they could not. I was then advised that I could personally make the request, and when I tried, I was told that I could not. It took weeks–not an exaggeration–to simply identify the correct process for pursuing this network gap exception request. We’d make these requests, they’d languish somewhere in the insurance company’s cosmos, and when I’d follow up that’s when I’d be informed that the request hadn’t followed the specific procedure for my policy. MADDENING.
For anyone, however, who is able to make their own request, here is a sample letter to accompany your request. This template was given to me by my midwife’s billing agency:
December 12, 2012
P.O. Box 12345
City, State, Zip
Member ID # 123456789
Request for In-Network Exception
To Whom It May Concern:
I write to request an in-network exception for maternity care to be provided by my midwife, XX. I am requesting that the midwife services from dates of service May 04, 2012 through April 20, 2013 be authorized to pay at the in-network level for based on the following reasons:
1. XX is educated, trained and licensed as a midwife. Maternity and newborn care is within her scope of practice per state code.
2. The services provided by a midwife are very cost effective. Midwife services on average, will cost an uninsured individual $4,000 – $6,000. A typical hospital birth will range from $10,000 to $60,000. This reflects a savings for both you as an insurance company and me as a member.
3. There aren’t any contracted midwives within a 30 mile radius who will perform a home birth (use this sentence if you know this to be true).
4. Basic CPT and diagnosis codes that will need to be approved are as follows:
Mother’s Dx: V22.0
CPT Codes for professional services to be billed on a CMS1500 form:
59400-Global OB care
59410-Delivery & PP Care
59425/59426 Global AP Care
99203/99204/99205 Office visit
Baby’s Dx: V30.2
5. Please put your personal reasons for wanting a home birth with a midwife here.
I trust this information will help you in your decision to authorize these services at the in-network level. If you have any questions, please feel free to call me at phone number.
The final bit of instruction was this: I needed an in-network provider to make this gap exception request. I was first told that my former OB–the one whose practice I’d left over birth philosophy differences–needed to make this request. I attempted to explain that my OB was no longer my prenatal care provider. Why would a provider no longer providing care to a patient make such a time-involved request on their behalf? My records at that point had already been transferred to my new provider. Nevertheless, I called my OB’s office and respectfully and directly explained my issue; they respectfully and directly told me that they would not make the request, as I was no longer receiving care there. Made sense.
I was then told that ANY in-network provider could make the request on my behalf. Problem? I was connected with no other in-network provider. I didn’t have a primary care doctor or a family doctor. I haven’t needed one since I moved to STL less than a year ago. It seemed completely ridiculous that I’d have to set up an appointment with a PCP or family MD for the sole purpose of having them interface with my insurance company to request that my midwife’s care be covered.
I obtained a few recommendations for area doctors who have a reputation for supporting home birth and made an appointment. I felt so ridiculous explaining to the nurse at the beginning of my appointment that I was perfectly healthy and was essentially using them in an effort to make a gap request. The nurse was good spirited about it. The doctor was even kinder. She boggled at the bureaucracy of it all, said that she was a big advocate of home birth and that she felt I deserved to have the birth I wanted, and instructed her nurse to initiate the whole process for me. RELIEF.
An additional hiccup later (the nurse supposedly made the wrong kind of request–surprise) and the network gap exception request was finally and legitimately sitting in someone’s inbox for review. It only took 10 weeks.
A week later I had a letter in my mailbox explaining that my request had been approved and that my midwife would now be considered an in-network provider. I nearly shit myself. If there had been any alcohol in the house, I would have consumed it in teary-eyed celebration. Finally, it appears that my home birth will be covered. I will hold onto this letter for dear life. (Well, it should be covered beyond the satisfaction of my in-network deductible, which has been nearly met.)
So, tips for pursuing coverage for your home birth?
- Enter this process with an expectation that it will be time-involved and cumbersome. If your process flows more smoothly, awesome! But, um, don’t count on it.
- You are, basically, the foreman of this whole process. Do not take for granted that someone on the other end of the phone has done their job. Do not wait for them to call you back. You call them–follow up every day if you have to. Be persistent, annoyingly so if you must.(For example, my new family doctor’s office called to tell me that they’d put the gap request in. The following morning I called the insurance company to ensure that this had been correctly done. It supposedly hadn’t. I made sure that the request was then submitted again, this time correctly. If I’d have waited, more time would have been lost.)
- Seek coverage for your provider. I posed the entire inquiry as provider-based–here is this caregiver whose services I wish to have covered. I never once explained that I was planning a home birth. No one ever asked where I planned to birth my baby, and I did not volunteer this information at any juncture. Would that knowledge of an intended home birth have colored the insurance company’s decision? I wasn’t about to risk the chance.
Here are some additional resources regarding pursuing insurance reimbursement for home birth:
- Bring Birth Back Home’s How We Got Reimbursement from our Insurance Company for Our Out of Network Home Birth
- GentleBirth.Org’s Negotiating for Health Insurance