I know that insurance is confusing. And there is a tremendous amount of political arguing over health care and who "deserves" to receive the benefits of health care. I personally believe health care is a basic human right, that every single person on this planet deserves access to good, quality health care, but that is for another blog.
Insurance and health care politics directly affects you. Preexisting condition protection is always under threat, health care is so expensive most people can not afford it, and now health care facilities are the single driving industry in many American small towns. America is simultaneously getting poorer and sicker. There are many insurance companies, including Blue Cross Blue Shield and Humana, that will not pay for a Licensed Midwife. United Health Care refuses to grant Gap Exceptions to out of network midwives. See the postscript as to why midwives often don't participate in insurance networks.
I thought we could take a look at one part of the Affordable Care Act that directly affects those interested in hiring a Licensed Midwife for their care.
In section 300gg-5. Non-discrimination in Health care
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State Law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. (Emphasis mine)
This section in the Affordable Care Act is essential in getting your insurance company to reimburse your Licensed Midwife.
Many insurance companies are confused about the different kinds of midwives. For years, insurance companies only knew about Certified Nurse Midwives. Some never differentiated between Nurse Midwives and Certified Professional Midwives. And now, more and more, insurance companies are actively discriminating against Licensed Midwives. Those insurance companies are breaking the law and you, the insured, have the right to pursue payment and reimbursement for services performed by a midwife practicing within the scope of her license.
In Texas, midwives are licensed. We have a political structure in place that governs and regulates the practice of midwifery. It is against the law to practice midwifery without a license in Texas. Therefore, every midwife you meet in Texas is covered under the Non-discrimination section in the ACA because every midwife is "acting within the scope of that provider's license or certification under applicable State Law."
It is interesting to note that the licensing of midwives varies state by state. There are some states, like Texas, that support midwives and your right to midwifery care. And there are some sates, like Illinois, that actively discriminate and persecute midwives. Midwives Alliance of North America can show you the laws, consumer and midwifery organizations in your state.
If your insurance company is refusing to pay for your midwifery services, know that you have rights. You pay a lot of money for your monthly premium and that money should be working for YOU, not the insurance company.
If you are my client, and you are interested in pursing your insurance company and forcing them to pay for the care you receive from your licensed midwife, let me know. I know my insurance biller would be happy to help.
PS - Why don't midwives participate in insurance networks?
There are several reasons why. When a care provider contracts with an insurance company, the insurance company sets the limit on how much the care provider can be paid. This is known as an "allowable amount." This amount is set by an industry standard. When you have a baby, the industry standard is medical obstetric care.
Midwifery care is different than medical obstetric care. Most of you choosing a midwife already know this. Midwives provide care that is far more extensive, both in knowledge and in time, to their clients. In a venn diagram, there are definitely some overlapping areas of knowledge and practice. However, in real life, a midwife spends FAR MORE time with her client than a doctor. In my estimation, a midwife provides at least 25 hours of hands on, face to face care, compare to the approximately 6 hours of care provided by a physician. And this does not include the immediate access you have to your midwife, day and night, if a question or issue should come up between visits. I don't know of one single doctor (I could be wrong) who offers this kind of access to their patients. This is priceless.
Most allowable amounts from insurance companies in regards to obstetric care are around $1500-$2000. If you do simple math, paying the midwife and the physician the same amount of money, the physician makes $250-340/hour on your care alone. A midwife on the other hand makes $60-80/hour. That difference is staggering.
Additionally, the average cost of a hospital birth is $10,000-20,000, when its all said and done (doctors fees, hospital fees, lab fees, prescription fees, other care providers fees, surgery fees, etc.). A midwife typically charges between $3,500-6,000 (depending where you are in the state of Texas). Now it is common for people to have large deductibles. If you have a $10,000 deductible, none of your hospital birth will be paid for. That is a lot of money to put aside in addition to the monthly premiums you are already paying.
Obviously, it is in the insurance company's best financial interest to pay for midwifery care if you are just looking at general costs alone. When you add a financial analysis to the significantly better outcomes with midwifery care, you are looking at hidden costs not generally calculated in overall maternity costs. Because insurance companies continue to break the law and discriminate against licensed midwives, it is clear that insurance companies are not making decisions solely based on finances.