Homebirth and Insurance: How It Works

While I am not currently practicing, this is the information I provided to families in my practice about homebirth and insurance reimbursement. I hope you find it helpful!

Congratulations on choosing homebirth! Planning for–and paying for–your planned homebirth requires some preparation. One of the biggest issues families face is understanding possible insurance coverage. This is not intended to be everything you need to know about insurance and homebirth, but to provide you with some idea of what to expect if you would like to seek insurance reimbursement.

Homebirth midwifery care is not obstetrical care; however, our only billing option is in obstetrical care.  Women come to homebirth for many reasons, but the most common are the style and continuity of care offered only by homebirth midwives. This care is not properly understood (or compensated for) within the insurance billing system. Some ways my care differs from a hospital-based practitioner (OB or CNM) include: 

• I take a limited number of clients per month so that I will be truly present for you, not just at your labor and delivery but also prenatally.
• Prenatal visits last an entire hour rather than 5-10 minutes.
• Because I know you so well, I am able to advocate for you when necessary in ways that go far beyond standard medical care. Every pregnant person is not the same. The psych/social aspects of a particular pregnancy are frequently relevant to their needs and the clinical picture during maternity care. They are also mostly invisible to a hospital practitioner. Anxiety, history of abuse, prior birth or other trauma, relationship issues, financial strains, or illness/death of a loved one can all impact your pregnancy and labor; my advocacy can help facilitate the best possible outcome for your particular circumstances. 
• With rare exceptions, I am on call for you through your entire due window (37-42 weeks).
• I am almost always on call for you through your entire pregnancy, enlisting a backup midwife only rarely.
• I ensure that you meet the midwife/assistant planning to attend your birth.
• In addition to being primary caregiver like an OB (prenatal care/baby catcher/decision maker), I also function as the labor and delivery nurse (monitoring labor) and pediatrician (assessing baby after delivery).
• I do not do shift work, meaning I will remain with you through the entire process. The second midwife may provide respite in the event of a long birth, but you will not be left alone in active labor.
• I am easily accessible between visits for questions and concerns.
• I don’t share call with a large group of practitioners you’ve never met. Most of the time you will get me on the phone, not a backup.
• I do home visits in the postpartum period for mom and baby, so you can rest, recover, and avoid the germs of the doctor’s office.

By comparison, an OB may have 6 “birth call” shifts per month, 10 clinic days, deliver a dozen babies (or more!), have met only two of those women prenatally, and spend less than 12 hours total with those birthing women. OBs work extremely hard and deliver more babies, no doubt, but their care is very different.

These differences in care are not considered with insurance reimbursement.  They are, however, things I know to be extremely valuable for health outcomes. In particular, I believe my clients’ extremely high vaginal birth rate, very low medical induction rate, and almost 100% breastfeeding at 6 weeks rate provide evidence of the quality of this type of care.

So for the insurance…

1. Everyone has different insurance. There is no guarantee that any particular plan will reimburse for prenatal and birth care from me. I’ve seen it all: insurance plans that claimed they wouldn’t but then did; ones that stated they would but then wouldn’t, no matter what we did or how many appeals we sent; ones that would pay for prenatal care but not the birth. I even had a plan that paid and a year later requested the money back and sent me to collections for it.

2. There is no way to know in advance how much insurance will pay. 59400 is the “big” code we generally bill. It’s called Global OB and includes routine prenatal care (not labs, ultrasounds, etc), delivery of the baby/placenta, and routine care for the mother through the six-week checkup. It’s the “dozen eggs” you may have heard me discuss.

3. There are times when 59400 cannot be billed: if your insurance changed late pregnancy so there wasn’t “enough” prenatal care to meet requirements for the global code, or if we went to the hospital. 

4. If we don’t bill 59400, we will bill other things (individual office visits, face to face time, postpartum visits, the delivery itself, etc.) and the reimbursement will vary based on that. We cannot know until after the delivery if we will bill 59400.

5. Even if we bill 59400, different plans within the same insurance company allow very different amounts for that code. I’ve seen them allow as much as $4200 and as little as $1500. Then, from that amount, the plan further designates what percentage of the allowed amount they will actually pay (it could be 70%, it could be 100% or any other number).

6. Reimbursement is also affected by your deductible. If you have a $6000 deductible, then you will be required to have paid that before insurance will cover anything. You cannot get back money that your plan states you have to pay toward your deductible, copays, and coinsurance. Also see “allowed” above.

7. At times, what is called an “in-network exception” can be obtained from your insurance company, allowing reimbursement at higher levels by having me temporarily considered an in-network provider. However, this can be tricky. If your insurance offers a low amount for 59400, then a midwife will likely not be able to agree to the in-network exception because she cannot collect money from you beyond that amount.

Remember that you have chosen a planned homebirth with a licensed midwife precisely because of many of the points listed on the other side of this paper: you want the style and continuity of care that is offered only by a homebirth midwife.

We ask that you take these things into consideration when you get frustrated if it feels like your insurance isn’t reimbursing enough or is requiring appeals, etc. It is most definitely not because my insurance biller and I haven’t worked as hard as we can to get the best possible legal reimbursement for you. It is because factors outside our control makes this a challenge.