My fight with TRICARE to have the birth I want

January 17, 2010 · 21 comments

The bureaucracy

The bureaucracy

When I started this blog I didn’t want it to be about me. Although I’ve added my opinions and snippets about what my family does, I’ve tried to keep the main topics about bigger things than me. As I’ve gone through this struggle with my insurance company though, I decided this personal story is worth sharing, for a few reasons. First, my insurance company, TRICARE, is paid for with tax dollars — that’s you!. Second, I want people to see how difficult it can be to have a natural birth without interventions. Woman should have a choice about how to give birth, and should not be forced in situations where medical interventions are the norm. This is the fight I’m in now, and I hope it resonates with you.

The problems with my insurance started when I became pregnant. My husband is in the military, and we carry the TRICARE insurance they offer. There are two designations in our area, TRICARE Prime and TRICARE Standard. I was on Prime, which operates like an HMO and gave me priority access to the military medical facilities, where all my medical expenses were covered without co-pays. If I wanted to see any other caregivers, though, I would have to pay out-of-pocket, or switch to TRICARE Standard, which is like a PPO and allows me to see outside providers. There were some stipulations to switch. On Standard, patients pay co-pays for doctors visits, and are barred from returning to Prime for one year. However, I was told Standard paid 100% of maternity and labor & delivery, and since I am otherwise in excellent health, to switch was an easy choice for me. I had a wonderful experience having a water birth at a birthing center with my first birth, and I want to have the same experience for my second. I happily began my prenatal care at Best Start Birth Center, which cared for me during my first pregnancy, and looked forward to the birth I wanted.

Then my husband received orders for us to move from San Diego to a small base about four hours away, China Lake Naval Air Station. I immediately began to look at my options for maternity care in Ridgecrest, the town outside the base. There is no birthing center. The closest one is over three hours away. The local hospital has two obstetricians and no midwifery services, and a 40% C-section rate. The closest hospital with midwifery services is over three hours away.There is one midwife, a Certified Professional Midwife (CPM), who attends home births and will come to Ridgecrest. When I contacted her, we discussed my situation, and she said she would be happy to take me on as a patient, but warned me that TRICARE had stopped reimbursing patients anything for her services, which cost about $5000.

With this in mind, I began research on my insurance. I spoke to customer service agents and their supervisors, and read every TRICARE document I could find, from their coverage policies to billing policies. This is what I found:

1. TRICARE Standard coverage of maternity care includes prenatal office visits, medically necessary ultrasounds and tests, and hospital admission for labor & delivery. If a woman is being seen by a doctor and has her baby at a hospital, the doctor is required to bill for all the services using distinct billing codes. If a woman is being seen at a birth center, the birth center may bill at an all-inclusive rate, since the services provided by midwifery care don’t always fit into traditional medical billing codes. If a woman is being seen by a provider for a planned home birth, the services are covered, but only if the provider can be certified as a TRICARE authorized provider, and only for the services that fit into traditional medical billing codes, since they are not authorized to bill at an all-inclusive rate for home births.

2. TRICARE will only certify Certified Nurse Midwives as authorized providers. They exclude all Certified Professional Midwives (CPMs), even in states where CPMs are recognized and licensed by the state medical board (which includes California).

What these two things mean for me is TRICARE will not cover this planned home birth. If I stayed in San Diego or other large city, I would likely have other options than going to the hospital for my labor & delivery. However, in the small town of Ridgecrest, the CPM or the hospital with a 40% C-section rate are my only options. I wrote a letter to TRICARE, which you can see here, explaining my situation and providing 13 pages of evidence about the safety of home births, the ability of CPMs to provide better outcomes than hospitals with fewer interventions, how the prevalence of C-sections in the U.S. contributes to our poor worldwide standing in maternal and infant mortality and morbidity, how TRICARE otherwise supports midwifery and natural birth practices, and how the cost of a home birth is only a third of what they would pay for a hospital deliver. What I received back from TRICARE is here, and it essentially says that they can’t give me an answer about whether they would authorize my home birth or not because I haven’t filed a claim for it yet.

It is hard for me to express the frustration I feel with this. One of TRICARE’s documented patient rights is the right to information (see page 15 of my original letter), which I hope would include understanding what they will reimburse me before I pay $5000 out-of-pocket. I’m not asking for special treatment, for experimental treatment, or outrageously expensive treatment. I am asking for a less expensive and less invasive option. I need to respond to TRICARE’s response today, but I feel as though I am talking to a brick wall. Before I wrote my original letter to TRICARE, I spoke to customer service agents who told me that the home birth with a CPM would be covered, supervisors who corrected that but then told me I had no recourse, and other customer service agents who told me my only option to change the standing rules would be to write my representative (who will be CC’d on this correspondence). TRICARE has the time and resources to sandbag me for as long as they want. Strangely, it’s fine with them if I get a C-section, although it will cost thousands of dollars (your dollars!!!) more. But it’s not okay with me. This is my body, my child, my birth. If there is no medical reason for interventions such as continuous fetal monitoring or an IV, I don’t want it. I don’t want things strapped to me during labor, I don’t want needles poked in my arm. I know how to give birth, and I should be allowed coverage for a medically qualified, supportive attendant that respects that.

I will let you know the response I get.

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