Billing, reimbursement, claims, deductibles.. OH MY!!
What does this mean for planning a Home Birth?
Lets break it down:
As a Licensed Midwife/Certified Professional Midwife attending Home Births
I am considered an out-of-network provider, as do the vast majority of Licensed Midwives in NM attending Home Births.
What puts us in-network or out-of-network is ultimately the ability to carry
and access Malpractice insurance. I do not carry malpractice insurance.
Not only is not easily available to Licensed Midwives, but it is very expensive.
In-network Provider: Refers to providers (doctors, nurse practitioners, midwives etc.) or health care facilities that are part of a health plan’s network of providers which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at a lower cost to the insurance companies with which they have contracts. The provider’s contract with the insurer requires the insurer to accept the insurer’s payment (plus the patient’s cost-sharing, such as the deductible, copay, or coinsurance) as payment in full — an in-network provider cannot balance bill a patient.
Out of network Provider: Out-of-network means that a doctor or physician does not have a contract with your health insurance plan provider. This can sometimes result in higher prices. Some health plans, such as an HMO plan, will not cover care from out-of-network providers at all, except in an emergency.
Out-of-network means that as a Licensed Midwife I do not have a pre-arranged contract with your health insurance plan. Typically, once a claim is sent to your insurance, if they are NOT going to cover a certain amount or none at all, the patient/client is then responsible for the billed amount.
HMO Plans: With this type of plan, you will likely be more limited to the provider network of the HMO, and you will most likely need to choose a primary care physician (PCP) for all referrals. HMOs usually have lower premiums than other plan types, such as PPOs. HMO plans don’t include out-of-network benefits. That means if you go to a provider who doesn’t take your plan, you pay all costs. Homebirth is always excluded from a covered cost.
PPO (preferred provider organization) Plans: As the name suggests, these plans have preferred providers that have been selected for your use. While the insurance company does prefer you use their chosen, in-network providers, there is some flexibility with going out-of-network—it just may mean the insurance company covers less of the care rendered outside of the network. PPO plans are more likely to "allow" or partially cover homebirth.
Deductibles: The amount you pay for covered health care services before your insurance plan starts to pay. For the majority of the claims I submit on the the behalf of clients, the amount billed typically goes towards the deductible, thus no reimbursement is made back to the client.
So, what does this all mean??
Since we do not know how much, if anything, your insurance will reimburse High Desert Midwifery for your care, clients with private insurance make payments towards the fee of $6000 throughout your pregnancy, paid in full by 37 wks.
Once your baby is born, I submit claims for both you and your baby to your insurance company. If they do reimburse something to High Desert Midwifery, I then reimburse that amount from your insurance back to you. It's hard to say how much they'll ultimately cover. It ultimately depends on your deductible, and out of network benefits. Many times, the billing I do for clients helps meet the deductible.
Since I'm a small/independent practice, I am unable to carry the financial risk of billing and collecting my fee after your baby is born. Sadly, I have encountered on three occasions, where I gave grace for waiting until after the baby was born, I was not paid by the client when their insurance did not reimburse for the care I provided.
What if I qualify for Medicaid?
If you qualify for Medicaid and you still have or choose to keep your private insurance plan, this is commonly referred to as "Primary private and Secondary Medicaid". Collecting the fee of $7000 throughout your pregnancy still applies.
Once your baby is born, I have to first submit a claim to your primary insurance to see if it is applied towards your deductible or if they reimburse. Once I receive the EOB (explanation of benefits), I then bill Medicaid (I only accept BCBS and Presbyterian Centennial). If Medicaid sees that the claim amount went towards your deductible or payment was made, Medicaid will not cover any remaining amount to meet my fee, thus the client unable to receive refund from High Desert Midwifery.
If you do qualify for Medicaid, I advise you to drop your private insurance plan. For clients on just Medicaid, only the deposit and the fee for travel outside of Abq applies.
Medicaid recipients
Please note as of January 1st 2023 I am no longer accepting Medicaid due to extreme frustration in receiving very little, to on-going NO reimbursement from the MCO's for the care I have provided to my clients.
Here is some important information you should know about Medicaid reimbursement for Homebirths:
Births occurring at home:
Medicaid pays $1700. which is approximately 1/3 of my fee of $7000. This is currently the contracted reimbursement for all homebirth midwives from Medicaid in NM.
For the routine newborn care we provide, Medicaid reimburses approx. $400-$800.
Transfer prenatally or during labour:
Should a transfer occur prenatally or during labour, we can only bill for the services provided which is called a split claim. Average reimbursement from Medicaid: $300-$800. This includes all the prenatal visits (avg. 12) and/or anytime spent caring for you in labour.
Average reimbursement for limited newborn care due to transfer: $250-$350.
We humbly ask families for your support and to consider making a monetary donation to help offset the very little amount that Medicaid pays for homebirths. This helps us still continue to provide services for clients on Medicaid.
Think of it in these terms: for a straight-forward birth in the hospital, the cost averages; $15,000-$20,000!!
In a homebirth, you receive tailored, individualized midwifery care at a fraction of the cost of a hospital birth!
Currently, High Desert Midwifery is one of 5 homebirth midwives in Abq still accepting Medicaid.
Here is some important information you should know about Medicaid reimbursement for Homebirths:
Births occurring at home:
Medicaid pays $1700. which is approximately 1/3 of my fee of $7000. This is currently the contracted reimbursement for all homebirth midwives from Medicaid in NM.
For the routine newborn care we provide, Medicaid reimburses approx. $400-$800.
Transfer prenatally or during labour:
Should a transfer occur prenatally or during labour, we can only bill for the services provided which is called a split claim. Average reimbursement from Medicaid: $300-$800. This includes all the prenatal visits (avg. 12) and/or anytime spent caring for you in labour.
Average reimbursement for limited newborn care due to transfer: $250-$350.
- Please note, there is no reimbursement available from Medicaid for labour/birth support in hospital should you transfer in pregnancy and/or labour. Should you desire any "Doula" support in hospital from your midwives and/or student midwives, the fee is $1200.00.
We humbly ask families for your support and to consider making a monetary donation to help offset the very little amount that Medicaid pays for homebirths. This helps us still continue to provide services for clients on Medicaid.
Think of it in these terms: for a straight-forward birth in the hospital, the cost averages; $15,000-$20,000!!
In a homebirth, you receive tailored, individualized midwifery care at a fraction of the cost of a hospital birth!
Currently, High Desert Midwifery is one of 5 homebirth midwives in Abq still accepting Medicaid.
