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HMO and Midwife
Hello,
My wife and I (and the one on its way) need your help. The first child for my wife and I was born under the care of midwives. And the cost was covered by insurance. And it was simple and direct and efficient and cheap. Since then, our insurance company dropped UCSD Health Care (which provided the midwives), but not, necessarily, the midwives themselves. So, now we are with Sharp HMO. And my wife is pregnant again, And she wants the midwife program. And we are running confused because Blue Shield will not let us go to the ones we are used to, and the Sharp HMO does not provide midwives. As I understand, if an HMO cannot provide a request, the member has the right to go out. However, as I speak with the HMO, they use the term "go out" loosly enough to suggest that we must pay for it. Frankly, I do not know the language to use in these discussions. Being cynical, I suspect that the HMO does not want to formally deal with this issue. And Blue Shield... the same. So may I ask how I begin. We are about to make the first appointment with Sharp HMO and then we will insist on a midwife program. We found that the midwives encourage natural births, handle the infant more naturally, and so on... We are prepared to state reasons. We wish to avoid the industry of birth in favor of a more natural approach. I feel I can phrase the need for the midwives but fear that I do not understand the "lingo" of HMO's. Can someone step in and advise us? Thanks, Tom |
#2
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HMO and Midwife
Mr. X wrote:
The first child for my wife and I was born under the care of midwives. And the cost was covered by insurance. And it was simple and direct and efficient and cheap. Since then, our insurance company dropped UCSD Health Care (which provided the midwives), but not, necessarily, the midwives themselves. So, now we are with Sharp HMO. And my wife is pregnant again, And she wants the midwife program. And we are running confused because Blue Shield will not let us go to the ones we are used to, and the Sharp HMO does not provide midwives. As I understand, if an HMO cannot provide a request, the member has the right to go out. However, as I speak with the HMO, they use the term "go out" loosly enough to suggest that we must pay for it. Frankly, I do not know the language to use in these discussions. Being cynical, I suspect that the HMO does not want to formally deal with this issue. And Blue Shield... the same. So may I ask how I begin. We are about to make the first appointment with Sharp HMO and then we will insist on a midwife program. We found that the midwives encourage natural births, handle the infant more naturally, and so on... We are prepared to state reasons. We wish to avoid the industry of birth in favor of a more natural approach. I feel I can phrase the need for the midwives but fear that I do not understand the "lingo" of HMO's. Don't take this as gospel because I'm no expert, but my hunch is that the rule you're talking about says that if a service isn't available through the HMO, you can appeal and try to get them to cover an outside provider for that service. However, your HMO clearly *does* provide obstetric services, just not from your preferred care provider, so I suspect you don't have much of a chance here. They're likely not to see much of a difference between an OB and a midwife, since they both provide the same services. Also, do you know that the insurance doesn't cover any other midwives? Basically, if you needed a lung transplant and none of the in-network physicians could do that, then you'd have a chance that they'd pay for you to go out of network to get the service you need. But even if they don't cover the midwives you want, if you can have your birth attended by someone in network, they're not likely to pay. You *might* be able to get somewhere claiming that you want *midwifery* care, not an obstetrician, but even then, if they offer any other midwives in network, they're very unlikely to pay for out of network midwives. HOWEVER, rules for these things can vary dramatically from state to state and you should definitely keep pressing the issue. Don't be afraid to ask to talk to someone higher up in the system until you're sure you're getting a clear and accurate answer. For us, we have paid out of pocket all three times in order to get the homebirth midwives we wanted because our insurance company didn't cover. The third time, the insurance covered some of it (the in office visits) at the out of network rate (ours is a PPO, not an HMO, so there is some coverage for out of network services), but not for the birth itself as they refuse to cover homebirths at all. If you end up paying yourself, look into using a medical savings account to pay, as that will at least result in some tax savings so you'll be paying with "cheaper" money. Best wishes, Ericka |
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