The couple’s Blue Shield of California HMO plan, which they have through her job as an executive assistant at a credit union, doesn’t have midwives or birth centers available in the couple’s network. When Stephanie asked her ob/gyn to approve a request for her to use a non-network nurse midwife, he declined, as did Blue Shield.
In its denial letter, Blue Shield said her plan allows for the coverage of midwife services. But it noted that since there are none available in her medical group, she was limited to using any participating obstetrician.
“If someone can get better, less expensive care, why are their hands tied?” says Stephanie. “People should have the right to choose what’s best for them.” She and her husband decided to pay the $5,500 charge for the midwife and birth center on their own. Their baby is due in April.
Blue Shield of California declined to discuss the details of Stephanie Taylor’s case. In an email response, the company said that generally people insured through an employer-provided HMO “must access medical services from providers within the plan network in order to be covered. While some exceptions exist, going outside the plan network is rarely authorized when providers within the network are able to offer maternity care."
Under the health law, maternity and newborn care is one of the 10 essential health benefits that must be covered in individual and small group plans unless they have grandfathered status. But the law doesn’t require that specific types of providers be covered, says Dania Palanker, senior counsel at the National Women’s Law Center.
Starting this year health plans are prohibited from discriminating against licensed or certified health care providers who want to participate in their networks. However, the law says, insurers aren’t required to contract with any particular provider.
Midwifery and birth center advocates say they’re uncertain how the nondiscrimination provisions will be applied or enforced, and the Department of Labor says it’s not issuing any further guidance.
“It leaves us in the dark,” says Jesse Bushman, director of advocacy and government affairs at the American College of Nurse-Midwives.
It can be difficult to learn whether a health plan covers a particular service or provider, particularly on the health insurance exchanges, say advocates. Kim Dau, chair of the policy committee at ACNM’s California affiliate, has been trying to learn the extent to which nurse-midwives are included in plans on the California health insurance marketplace. Sometimes certified nurse-midwives are incorporated into physician directories and hard to find in a search, she says.
For consumers, if having access to a midwife or birth center is important, the best and perhaps only remedy is to call the plan directly and ask about coverage.
Mon, Mar 03 2014