This is a re-post of a blog I wrote on my personal website. I wanted to post it here in a community supportive of natural birth to spread the word about the difficulty some women have in getting insurance coverage for midwifery care or home birth. If you have any insight for me, please email me: suchada@mamaeve.com. Thank you for taking the time to hear my story:

When I started this blog I didn't want it to be about me. Although I've added my opinions and snippets about what my family does, I've tried to keep the main topics about bigger things than me. As I've gone through this struggle with my insurance company though, I decided this personal story is worth sharing, for a few reasons. First, my insurance company, TRICARE, is paid for with tax dollars -- that's you!. Second, I want people to see how difficult it can be to have a natural birth without interventions. Woman should have a choice about how to give birth, and should not be forced in situations where medical interventions are the norm. This is the fight I'm in now, and I hope it resonates with you.

The problems with my insurance started when I became pregnant. My husband is in the military, and we carry the TRICARE insurance they offer. There are two designations in our area, TRICARE Prime and TRICARE Standard. I was on Prime, which operates like an HMO and gave me priority access to the military medical facilities, where all my medical expenses were covered without co-pays. If I wanted to see any other caregivers, though, I would have to pay out-of-pocket, or switch to TRICARE Standard, which is like a PPO and allows me to see outside providers. There were some stipulations to switch. On Standard, patients pay co-pays for doctors visits, and are barred from returning to Prime for one year. However, I was told Standard paid 100% of maternity and labor & delivery, and since I am otherwise in excellent health, to switch was an easy choice for me. I had a wonderful experience having a water birth at a birthing center with my first birth, and I want to have the same experience for my second. I happily began my prenatal care at Best Start Birth Center, which cared for me during my first pregnancy, and looked forward to the birth I wanted.

Then my husband received orders for us to move from San Diego to a small base about four hours away, China Lake Naval Air Station. I immediately began to look at my options for maternity care in Ridgecrest, the town outside the base. There is no birthing center. The closest one is over three hours away. The local hospital has two obstetricians and no midwifery services, and a 40% C-section rate. The closest hospital with midwifery services is over three hours away. There is one midwife, a Certified Professional Midwife (CPM), who attends home births and will come to Ridgecrest. When I contacted her, we discussed my situation, and she said she would be happy to take me on as a patient, but warned me that TRICARE had stopped reimbursing patients anything for her services, which cost about $5000.

With this in mind, I began research on my insurance. I spoke to customer service agents and their supervisors, and read every TRICARE document I could find, from their coverage policies to billing policies. This is what I found:

1. TRICARE Standard coverage of maternity care includes prenatal office visits, medically necessary ultrasounds and tests, and hospital admission for labor & delivery. If a woman is being seen by a doctor and has her baby at a hospital, the doctor is required to bill for all the services using distinct billing codes. If a woman is being seen at a birth center, the birth center may bill at an all-inclusive rate, since the services provided by midwifery care don't always fit into traditional medical billing codes. If a woman is being seen by a provider for a planned home birth, the services are covered, but only if the provider can be certified as a TRICARE authorized provider, and only for the services that fit into traditional medical billing codes, since they are not authorized to bill at an all-inclusive rate for home births.

2. TRICARE will only certify Certified Nurse Midwives as authorized providers. They exclude all Certified Professional Midwives (CPMs), even in states where CPMs are recognized and licensed by the state medical board (which includes California).

What these two things mean for me is TRICARE will not cover this planned home birth. If I stayed in San Diego or other large city, I would likely have other options than going to the hospital for my labor & delivery. However, in the small town of Ridgecrest, the CPM or the hospital with a 40% C-section rate are my only options.

I wrote a letter to TRICARE, which you can see here, explaining my situation and providing 13 pages of evidence about the safety of home births, the ability of CPMs to provide better outcomes than hospitals with fewer interventions, how the prevalence of C-sections in the U.S. contributes to our poor worldwide standing in maternal and infant mortality and morbidity, how TRICARE otherwise supports midwifery and natural birth practices, and how the cost of a home birth is only a third of what they would pay for a hospital deliver. What I received back from TRICARE is here, and it essentially says that they can't give me an answer about whether they would authorize my home birth or not because I haven't filed a claim for it yet.

It is hard for me to express the frustration I feel with this. One of TRICARE's documented patient rights is the right to information (see page 15 of my original letter), which I hope would include understanding what they will reimburse me before I pay $5000 out-of-pocket. I'm not asking for special treatment, for experimental treatment, or outrageously expensive treatment. I am asking for a less expensive and less invasive option. I need to respond to TRICARE's response today, but I feel as though I am talking to a brick wall. Before I wrote my original letter to TRICARE, I spoke to customer service agents who told me that the home birth with a CPM would be covered, supervisors who corrected that but then told me I had no recourse, and other customer service agents who told me my only option to change the standing rules would be to write my representative (who will be CC'd on this correspondence). TRICARE has the time and resources to sandbag me for as long as they want. Strangely, it's fine with them if I get a C-section, although it will cost thousands of dollars (your dollars!!!) more. But it's not okay with me. This is my body, my child, my birth. If there is no medical reason for interventions such as continuous fetal monitoring or an IV, I don't want it. I don't want things strapped to me during labor, I don't want needles poked in my arm. I know how to give birth, and I should be allowed coverage for a medically qualified, supportive attendant that respects that.

I will let you know the response I get.

Tags: birth, care, centers, coverage, home, insurance, midwifery

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Everything you have pointed out is just common sense (but common sense isn't so common, right?). I sincerely hope that you are able to get the birth you want. Best of luck to you, and please do let us know how it turns out.
Kasie --

Thanks for the words of support. I will keep everyone up-to-date on what happens! Let's keep our fingers crossed . . . .

Suchada
I don't live in CA or have Tricare, but had the same issue w/my insurance. I petiotioned for a pre-authorization for prenatal care (they called it a GAP execption authorization). The response you received said that your provider would have to submit a new request authorization request for review. I think I would have the MW request a preauthorization to see how Tricare handles it. If they deny it then you will have grounds for an appeal. Also, check w/ the CA insurance board about your rights and options.

Good Luck!
Sara, thank you so much for this suggestion. I'd never even heard of a pre-authorization before, and if it's something I can do with TRICARE, they didn't mention it to me (although this is no surprise, since no one even told me there was a grievance process). I will talk with my midwife and see if it's possible. I will keep you updated!
Suchada, hang in there and continue to fight your corner! It sounds so frustrating but you lay out your case so clearly and reasonably that if you power on through all your provider's red tape and submit a pre-authorization for prenatal care as suggested by Sara and TRICARE's response, hopefully they will need to actually consider your case rather than send you jumping through another hoop. If they don't then I agree you should have grounds for appeal, particularly as you say CPMs are licensed in CA. Also, not sure if I'm being naive here, but since TRICARE Standard will only cover "services that fit into traditional medical billing codes, since they are not authorized to bill at an all-inclusive rate for home births," can you find out what these traditional medical billing codes cover exactly to assess how closely the services likely to be provided by a CPM may fit within these guidelines?

Good luck. I'm American but live in the UK and am planning a home birth, which is routinely covered by the National Health Service (NHS) and whenever I hear stories like yours I feel frustrated that home birth is subject to so many limitations in the US, be it by State, insurance provider, mass culture, etc.

Random Musings From a Pregnant American in London
Hi Tanya --

I'm so envious that you're in the UK and don't have to worry about all these regulations. I was just talking with a massage therapist who's from the UK and had both her children there, and she said the system worked so well for them.

When I've talked to other people about the billing code thing, they have asked the same thing, and it's just another point that frustrates me. I obviously don't understand the system terribly well, since I'm not in the insurance industry, but apparently the billing codes don't correspond very well at all. They are very specific, like, "10 minute office visit, non-urgent", or "30 minute office visit, emergency consultation". So if a midwife has a 30 minute routine visit, she either has to justify why the visit was urgent, or accept payment for 10 minutes. Then there are similar things for labor that don't cover the midwife staying the entire span of a 12 hour (or more) labor. This is part of the reason why doctors only show up to catch babies. My CPM said when her patients were reimbursed, it was for about 20% of their actual out-of-pocket costs (even though the total cost was a fraction of a hospital birth). Grrr . . . .
I've had two wonderful home waterbirths attended by CNMs as an active-duty TRICARE remote beneficiary. The second birth was only a week and a half ago, and it was so perfect!

Three years ago when I had my first child, TRICARE notified me two weeks before the birth that I could no longer use the midwives I'd been seeing, both of whom were state-licensed direct entry midwives whom TRICARE had been reimbursing in error. Those two direct entry midwives had just hired a CNM to be part of their practice, but her paperwork hadn't been processed by the state yet, so if that didn't happen by the time I went into labor, I'd have no local choice other than the hospital (which has a 40% cesarean rate). I looked at other options. The direct-entry midwives I'd been seeing offered to serve as doulas for me for free if I decided to use the local hospital. The local TRICARE rep told me that I could travel somewhere else that had a CNM who did out-of-hospital births and "accidently" have the baby in that area; it would have to be a place that didn't have a Military Treatment Facility, which I'd be required to use as a first option because I'm active-duty. (Being active-duty really restricts your birth options, depending on where you’re stationed, but that’s another story…)

I'm not sure if either of these ideas (doulas or travel) is feasible for you. Do you have any friends or relatives who live near a CNM and could put you and your child up for a little while, and is your husband's leave situation flexible enough that he could get there in a hurry? I’m not sure if TRICARE standard would allow this like TRICARE remote does.

I would happily have paid out-of-pocket the few thousand it would take for a home birth with the direct-entry midwives I’d been seeing, but the local TRICARE rep explained that if I needed to transfer to the hospital for some reason, or if the baby had any medical issues what-so-ever, I'd be responsible for those costs because I'd started with an unauthorized provider. The CNM's paperwork came through just in time for me to have the home birth I wanted, but I was really stressed out by the whole process.

The provision in the TRICARE regs that allows coverage of care by CNMs but not other midwives is actually written into the Code of Federal Regulations. Ever since I found that out, I've periodically been writing to my congressmen to ask them to change it. I'm assuming that the law was written before state licensing of direct-entry midwives became so wide-spread. Anyway, here's the text of my most recent letter to my congressmen, in case you'd like to write something similar to yours.

Best of luck with this birth!

THE LETTER:

As healthcare is discussed in congress in the next few months, please keep in mind that both Certified Nurse Midwives and state-licensed direct-entry midwives are underutilized alternatives to physician-led care for pregnant women. In addition to being a safe choice for women with low-risk pregnancies, midwives cost considerably less to insurers, particularly when they practice in out-of-hospital settings. I am not advocating that the government force women to choose the low-cost option, but I believe midwives should be an option for more women, and that that option should be supported more fully in federal regulation.

Mine is a case in point. I am a TRICARE beneficiary. Title 32 CFR 199.6 "TRICARE-authorized providers" allows for care provided by Certified Nurse Midwives (CNM), but does not currently allow for care from state-licensed midwives. (Medicare, as I understand it, has similar restrictions.) I received wonderful prenatal, birth and postnatal care from an Alaskan CNM during my first pregnancy and am again receiving care from a CNM at the same Juneau-based birth center during my second pregnancy. However, the other midwives at this birth center are state-licensed, not CNMs. Because the midwives practice collectively as a team, I sometimes see one of the state-licensed midwives for my prenatal appointments; they cannot bill TRICARE for their services, but they do not pass any of this cost on to me—essentially, they’re seeing me for free. This is not fair to them. The situation is also not fair to TRICARE beneficiaries who would like to use the birth center for their births, but end up being forced to go to the hospital if the sole CNM at the birth center is out of town or otherwise unavailable on their due dates. Expanding TRICARE’s authorized providers to include state-licensed midwives would expand women’s choices without expanding costs—particularly important in Alaskan communities, where healthcare choices are already limited.

Alaska has recognized state-licensed direct-entry midwives as competent birth professionals since the licensing program was put into place in 1992. It’s time for the federal government to follow the lead of states like Alaska (which cover care by direct entry midwives through programs such as Denali Kid Care) by including these practitioners as authorized providers in federal insurance programs.

Thanks for your consideration of this matter.
Brierely --

Thank you so much for the advice and recommendations. It has made me think even more about what my options are -- if I go with the CPM without authorization and something does happen, then I'm really in trouble financially. Honestly though, I just wish I had enough money to pay for her out-of-pocket and just be done with it.

I'm really glad you posted your letter to your representatives -- I will copy it and send it to mine (in addition to what I've already sent them), and hope that others will do the same. Thanks again for the advice!

~Suchada
www.mamaeve.com

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