Ultimate Guide to Home Birth Insurance Reimbursement

Jan 15

In 2016, I accomplished something most people believe is impossible - I was reimbursed 100% for my home birth midwife’s fee from my HMO insurance plan.

Disclaimer

The following is simply my opinion on what will help most in getting your insurance company to reimburse you fully for an out of hospital birth. I am not a medical professional, insurance biller, insurance agent, lawyer, nor have I ever worked in any of those fields. I am simply a birth worker and a mother who has gone through this process herself, and has helped others do the same, so I’ve done a fair bit of research to form the opinions and suggestions expressed here. I do have experience working as a consumer relations representative so I know how these departments tend to work and generally what to say to get a better response.

The vast majority of birthing people in the United States are still having babies in a hospital setting. This is our “normal”, but it’s relatively new given human history. While we are certainly thankful for modern technology and its ability to help the people who need it, unnecessary intervention and cesarean rates continue to remain high. More and more families are seeking an alternative to maternity care with an OBGYN and a hospital – the problem then becomes that they no longer fit within the current healthcare system that relies so heavily on medical insurance.

My hope is that with the information contained here, those of us choosing an out of hospital birth with midwives can begin a small revolution by getting insurance companies to see that undisturbed birth can be safer and less expensive, thereby shifting the culture that birth needs to always be considered a complicated and dangerous medical event. I want to #normalizebirth by getting insurance companies to pay for ALL births like they do for the ones in the hospital!

Initial Considerations

The most common way to get your out of hospital (OOH for short) birth covered, is by paying your midwife up front and getting the insurance company to reimburse you after your baby is born. This means you will need to be able to afford the midwife’s services initially (many midwives also take payment plans). If you cannot, you can ask friends and family for help donating to your “home birth fund” in lieu of traditional baby gifts, of which many are often not necessary in the first month of baby’s life anyway. Alternatively, I know some people get a credit card or loan with 0% interest for the first year and pay it off completely prior to the end of that year. Do not assume the insurance company will reimburse you, and end up in a stressful financial pickle – you’ll still have a baby to care for!!

This process will require strong motivation, dedication, and perseverance because it can be lengthy and difficult. It may require dozens of phone calls, even making the same phone call multiple times in the hopes you’ll get a friendly voice on the other end. DO NOT GIVE UP! Insurance companies like to say “no”, and it’s easy for them to say “no”, until they realize you are not going away. Also, some birth centers and midwives use billing services to help you get reimbursement from insurance. From my experience, relying on these people is hit or miss. For one, the insurance companies aren’t super motivated to work things out with a third party such as the biller – you are their customer, you’ll be much more influential. Secondly, the biller isn’t super motivated to really fight for you against the insurance carrier – again; it’s not their birthing experience so they just aren’t intrinsically motivated like you are. So, you may simply want to pass on using their biller and attempt all of this by yourself. More work? Heck yes, but likely a higher success rate as well.

My personal experience with getting my home birth reimbursed was through an HMO but I’ve learned many tricks to getting PPO coverage as well. You can listen to my podcast interview about my experience getting reimbursed over on Birthful.

The only exceptions that I feel pretty strongly that this information wouldn’t work for are:

Kaiser Permanente
Any government run health insurance like Medicare (or your state’s equivalent)
Military insurance (like Tricare, which actually does seem to be covering OOH providers more and more)

HOWEVER it doesn’t hurt to try anyway!! In California, Medi-cal recently got approved to begin contracting with Certified Professional/Licensed Midwives (as well as Certified Nurse Midwives) so it’s a step in the right direction, and the power of the consumer should not be understated. Kaiser is actually one of the biggest HMO systems that employs Certified Nurse Midwives (CNM) so that’s pretty great – in fact some of the ones here in Orange County, CA often work for the birth centers as well, and attend home births in that setting. As of now, most Kaisers won’t allow for home births with these midwives, but hey maybe with enough pressure from their customer base they will start to consider it. In fact in Washington I believe Kaiser has an option for home birth with their CNM’s and I have heard about some Kaiser’s allowing water birth within their facilities too so I KNOW shifts are happening! More and more insurance companies are feeling the push to cover out of hospital birth - Cigna recently announced this change too.

The main arguments that you will be making to your insurance company is that the services you want covered are:

A basic human right, despite not being in network with ANY provider (all birthing people deserve to birth wherever and with whomever they feel safest)
Statistically proven to be safe
Significantly less expensive than even the most straightforward vaginal hospital birth
If you have trauma from a previous hospital birth, preventing that for subsequent births is absolutely worth mentioning

Have questions about anything you are reading here? Need clarification, or simply advice on how to proceed next? Please reach out to me! I want you to be successful.

Important Suggestions Prior to Starting

Begin by taking some time to really read over exactly what your current insurance plan says they will/will not cover. You can request this detailed information from your HR department, by calling your insurance carrier directly, or through the member area on your insurance carrier’s website.
- Take screenshots or notes of items that you feel you could use as leverage for convincing them to cover your OOH birth- there is typically an entire section devoted to maternity care but look for things that pertain to out of network providers as well. Being really knowledgeable about your plan will also indicate to them that you are serious and not messing around!
Pick a notebook to use for all your notes throughout this process, and always have it with you when you make a phone call. If you get a call when you don’t have it, make a quick note on any scrap paper or your phone, and add that information to the notebook so you have everything in one place.
EVERY TIME you get someone on the phone, ask for his or her first & last name (sometimes they won’t give last name, that’s fine at least get the first name), and start an entry in the notebook with the date & time you called plus who you spoke to.
If you get transferred during the call, ask for the new name and their title (typically it’s a supervisor). Sometimes asking to speak to the supervisor if you are getting nowhere is a good strategy!
Before ending every call, if an action was discussed (say, the person is going to put an inquiry into another department, their supervisor, or they are submitting a request, appeal, etc) ALWAYS ask for the time frame in which you can expect a response. It helps to confirm by saying “So if I haven’t heard from anyone by *date*, I can call this same number to follow up? Can I speak to anyone or is there some way to reach you directly?” If there is a different number, department, or person make sure to write that information down.
Set a calendar reminder for the day after the day they tell you (if it’s a range of dates, like 5-7 business days, make the reminder for the 8th business day to give them a tiny grace period). Call back to follow up, ready with your notebook to take more notes.
If you submit an appeal, or get approved for an out of network exception, ask for a reference number!

Why does any of that matter? Well you can believe they are taking the exact same copious notes on their systems (plus the calls are recorded), which they may bring up in subsequent conversations in an attempt to get out of reimbursement if you can’t remember exactly what was discussed. For example… You: “The last person I spoke to told me this would be approved”, Rep: “Well I don’t know who you spoke to but we don’t approve that”. Normally the conversation would end there, unless you have info like “Well I called on *day* at *time* and spoke to *name* so maybe you can follow up with them about it, but I assure you that’s what was said to me. Perhaps it would be easier if I spoke to your supervisor about this instead?”

Ok… are you ready??

How to Begin

Call your insurance carrier and ask them to do a "search for a Certified Professional Midwife, CPM, or Licensed Midwife, LM, within 50 miles". This is how you start, and it's crucial to say "search" and "CPM/LM". They may have CNM's/hospital midwives so you want to make sure you stress CPM/LM if that is the type of midwife you want. If you want to search for a Certified Nurse Midwife (CNM), go ahead and use that term instead or include it with the others. It depends on your situation – I already had a midwife I wanted to use, who was a LM, so I didn’t want to look for just any CNM in the event they had one they’d cover.
Carrier will likely say, “we don’t have one in network” or “your plan doesn’t cover this type of service”, in which you would reply, “I would like an out of network exception/exemption letter then please”.
IMPORTANT: Remember to get reference number for the exception letter if you get one at this point!
Make sure the exemption letter covers you through a year after your due date. Their typical form only covers for three months.
You will include this letter when you submit your superbill from the midwife to your insurance company, like you would for any other claim.

If you have a PPO plan and your insurance carrier denies your request…

Make sure you get this denial in writing, after speaking to a supervisor preferably. Make it clear you would like to submit a formal appeal based on the fact that choice in where a person gives birth is a basic human right, so an exception needs to be made to have your midwife covered at in-network rates. You can also mention how much less expensive an out of hospital birth would be compared to even the least complicated vaginal birth in a hospital.
Submit a formal appeal (see reference links for appeals template) - jump down to “if your appeal is denied” if it’s initially denied.
Know that sometimes it’s just a matter of calling a few times to get different representatives or supervisors.

If you have an HMO plan and your carrier defers to your medical group…

Repeat step 1 above, and you may get same answer as insurance carrier. You would request exception letter the same way, but they may defer you back to insurance company. To reduce the back/forth at this point, request that their denial be put in writing (email or physical letter) to show the insurance company.
If they comply, follow steps 3-5 as above.

If insurance or medical group says you need a referral from your primary care physician (PCP)…

Call PCP and simply say you need a referral for a LM/CPM/CNM for out of hospital birth… see what they say.
If they refer you to your OBGYN, either say you don’t have one or proceed with asking OBGYN. If you don’t have one, try to push further to get referral from the PCP.
Same steps with OBGYN.
It is UNLIKELY either provider will write referral due to their liability insurance, but it’s worth trying.
1. If you do get a referral, follow up with medical group accordingly.
2. If the medical group approves, you are probably good! If they deny, you need to then appeal the decision to your insurance carrier. Call insurance, and say you’d like to file an appeal for your medical groups out of network referral exception denial. They will likely walk you through the appeals process.
If no referral is obtained, speak to medical group again and tell them you cannot get a referral. They will likely say your request is denied – ask that they provide this denial IN WRITING.

If medical group denies request and you need to submit appeal to insurance carrier…

Call insurance, and explain situation including medical group denial of your requested out of network exception (you may find yourself repeating a lot of the same information… having them search again, explaining why you need this, etc. My advice is to play along because you typically get a new person on the phone every time and you never know when you may hit the jackpot of someone who is REALLY willing to help you!). If they start down the same path of “we don’t do that/we won’t cover 100%” then simply state you’d like to appeal the decision of the medical group/insurance carrier. They will either tell you how to submit a formal appeal, or perhaps even help submit it for you over the phone right then and there.
The appeals process will look different for each insurance carrier so you’ll have to do a little research as to exactly what those steps look like. Every carrier has a straightforward appeals process so it’s probably listed on their website under customer service.
During the appeals process it’s even more important to ask for follow up dates and follow up once those pass. “Out of sight, out of mind” as they say, but you are on a time crunch so you can’t afford for them to forget you!

If your first appeal is denied…

APPEAL AGAIN! Try including a more persuasive letter that includes evidence based information for how your out of hospital birth actually saves them money. Remember they don’t really care about your emotional reasons for choosing OOH birth, they care about money (which is really what liability is all about) so just speak their language! See addendum for an example of an appeals letter you can use, and references to links for information about cost comparisons for hospital vs. OOH births. You may even want to ask around about the average cost for an uncomplicated vaginal birth at your nearest hospital, to use as a reference point against your midwives’ cost.

If ALL your appeals are denied…

There may be a regulatory organization run by your state that oversees health insurance consumer protection, and you can submit a complaint/appeal to them in an effort to get some help convincing the insurance company. You will have to do further research to see exactly where/who you would contact, but starting with your state’s government website is probably best.
- If you are in California, see addendum for links to the Department of Insurance and where to file a complaint.

If your appeal is APPROVED…

CONGRATULATIONS!!! You will either be notified by phone, by snail mail, or both. When you get your approval letter, immediately scan or make copies – this is your GOLDEN TICKET to reimbursement so you do not want to lose it!
After your birth, ask your midwife for a superbill. You will then submit this bill along with your out of network exception letter to your insurance carrier, using whatever process they outline for all claims. If you aren’t sure how to complete this, simply call them up and ask someone to walk you through how to submit a claim using a superbill.
Take note of how long you can expect to wait for your check, submit your claim, and make sure to keep following up again. It can take weeks, or even a few months to get that check.

Got your check? CONGRATS AGAIN!!! Do a happy dance with your sweet little baby, and send me a note telling me all about your success. Bonus points for a picture of you and your cute family!

Last step… SHARE this information! Help me spread the word – let’s get more people access to the birthing options they truly want!! Thank you so much for taking the time to read through this, I sincerely hope it helps you!

With love, Nicolle

References and links to more helpful information

5/8/2023 UPDATE

I’ve been hearing about many midwives who refuse to provide super bills, which to me is silly. Your midwife can simply buy a generic claim form like this one, fill in the necessary info, and send it to you for insurance submission.

For claim codes (cannot guarantee 100% accuracy):

Diagnosis code: Z34.83
Procedure code: 59400