HMO and Midwife

[Mr. X]

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

[Ericka Kammerer]

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