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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{ 19 comments… read them below or add one }

1 Heather October 29, 2010

WOO-HOO!!! We also fought with TriCare. I fought not only because of what I wanted, but for all the other mamas who may want something different. Every “fight” paves the way, puts another chink the wall, and makes it easier for US to choose our birth, not our insurance! GOOD FOR YOU!!!

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2 Ruthie October 29, 2010

I couldn’t find another update since Feb. Just wondering how everything turned out with your Tricare situation.

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3 Lizzy Korday October 31, 2010

yes, i’m curious too. please update us! thanks!!

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4 Cassie November 2, 2010

Wow, I have been looking for information on this. I hope you were able to get it figured out. We are pretty much resigned to paying out of pocket for our next birth.

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5 Maria November 6, 2010

I didn’t even attempt to talk TRICARE into covering the cost of the midwifery services I received 5 years ago. I was able to arrange a payment plan with my midwife, and although it took about a year to pay off (it was over $5000), it was worth every penny. I figure if I’m willing to pay $250-$300 for a car each month, why wouldn’t I be more willing to pay that amount for the best birthing situation for me and my child possible? Buying a car isn’t really much of an investment (if you consider the depreciation of value) compared to the HUGE investment of having a healthy, natural, loving welcome to the world for your child.

That being said, if you manage to get them to cover you, Fantastic! I can only imagine it will help others who are also wanting the same thing.

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6 Aimee January 6, 2011

I TOTALLY relate to you on this. I’m due w/our 2nd baby in a few wks and am having a homebirth w/a CPM also. Our first was born by C-sect…not my choice and I didn’t want another one. It’s been frustrating to say the least dealing w/our ins. co…PacifiCare, HMO. So, we just figure we are not getting reimbursed. We paid out of pocket also even though we could have chosen the conventional method w/$10 co pays to the OBGYN and a birth that would be paid for. The care I have received w/my midwife is priceless. We must advocate for midwives and fight the evil insurance companies! For the next baby, (God willing He blesses us again) I will use my current midwife again and will pay out of pocket again, but will do all I can to fight our ins. co first and try harder to get reimbursed

Don’t understand why they won’t fund/reimburse it when midwifery care is far more comprehensive, personal, you are not just a number, and it’s THOUSANDS of dollars cheaper! Go figure!

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7 Suchada @ Mama Eve January 7, 2011

Wow Aimee, that’s really inspiring. I’ve been frustrated lately with the lack of action and fighting regarding the advancement of midwifery legislation, but when I hear stories like yours I’m reminded why I advocate so strongly for it. I’ll have a new post soon on some developments (I hope — I keep putting it off but I recently attending the California Midwives Advisory Council and it was amazing!). Thanks so much for sharing — hope I’ll see you around the site again soon!

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8 Katherine February 4, 2011

I can attest to the fact that Tricare is extremely hard to deal with as well as Medicaid, I am a medical billing and coding professional I have first hand experience. The issue here and this goes for hospitals as well is that they have a perceived notion that the risk is too great and that they are liable for more medical cost as a result. I know it is back assward, but not much insurance or even government related isn’t. An example of this as it pertains to hospitals is the practice of not allowing women to eat if the need during labor. There is a whopping 1% chance that a women will need to go in a C-Sec under general anesthesia and run the risk of vomiting while under. 1% is all it takes for them to up the risk on interventions because women are become exhausted. Until the AMA declares home birth as safe as a hospital one it will be extremely hard to convince them otherwise.

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9 Anika July 19, 2011

i understand so good what is going on. we should have to have the right as a mom and female to give birth the way we want to and not how our insurance company will pay. i am in the same boat seeking for information to give birth the way i want to. makes me feel sad on one hand to see i am not the only one who is not given a choice and on the other hand it makes me happy to see that in a state where the c section ratio is 90% that there are still female out there who do not like it. i am from germany and our ratio is 30% and only because doctors are scared they do not wanna give me an option but i will fight just for my unborn baby to give him the welcome he deserves.
be strong to all the females the wanna do the right thing.

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10 Kduffey August 17, 2011

I am not due until march2012,but I’ve always wanted a totally unassisted birth,but my wonderful husband is just to scared by the idea,so after some re-thinking I finally got him to come around about having a midwife,but he still would rather me have our baby in a hospital,to be on the safe side,he doesn’t understand,that just because this is my first time does not mean I don’t know exactly what to do!! So with any luck I can convince him of a home birth,but from what I hear,its like jumping through rings of fire to get tricare to pay for it,is love to know how everything turned out for you,and hopes that we as women birthing are children come in to some luck if nothing else.good luck to you all!!

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11 beverly May 23, 2012

Hi Kduffy,

Have you had your husband watch the movie, “the business of being born”? i got mine to watch it and he seemed to at least warm up to the idea of home birth. i think a lot of it has to do with most men (actually people in general!) never having seen what one actually looks like. they have these scary ideas in their heads because of movies and tv. i would definitely recommend getting him to watch that movie! ;)

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12 Anika August 17, 2011

good luck to you Kduffey,
there are some good internet sides you can show your husband to help him understand that homebirth or birth in a birth center is most of the times safer than birth in a hospital. Where do you live? I just found a support group in my area. Tricare probably wont cover your wishes but to have a birthplan, a supporting midwife in that hospital and a Doula (out of pocket) would be the best bet to get the birth you want. Cause they cant do anything to you in a hospital you dont want and the Doula is making sure that they work with your wishes and not against it she also can support you and your husband before during and after birth. When you are in TX let me know i have lots of information.
Find the states Patient Bill of rights. look up the side from CIMS….this is another good source http://www.childbirthconnection.org/ and this one too
http://www.choicesinchildbirth.org…..this is the support group…http://www.meetup.com/CenTex-Birth-Circle/events/23151911/
and here is a side for a birth plan http://www.earthmamaangelbaby.com…….
hope that all helps and good luck to you…
its your duty to welcome your child the way you feel its best and to make it happen….all strength to you…

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13 Linda October 9, 2011

Hi girls, it really surprises me the Tricare does tell us (yes, even to me!) that a homebirth is no-no for them but look what I just found!
http://www.military.com/benefits/content/tricare/maternity-care-options-chart.html
The second line from the end of the chart mentions the home birth. Maybe I misunderstand it since English is my second language but does not it say you have $0 copay for a homebirth? If this says so, than I do not understand the whole situation at all. Seems I have another Tricare trip in my near future with a print of the chart… Linda

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14 Suchada @ Mama Eve October 9, 2011

Hi Linda,

Yes, TRICARE does cover home birth. However, it only pays for certain types of providers: physicians or Certified Nurse Midwives — the providers who are least likely to actually perform home births. For those fortunate enough to find an appropriate provider, TRICARE is great. However, excluding Certified Professional Midwives from the coverage leaves the vast majority of women without a certified provider, and therefore without a covered home birth.

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15 Noel September 10, 2012

I to am a military wife wanting a natural pregnancy and birth…Tricare does pay *about half of the fees associated using a midwife + a $300 deductible as long as your midwife is in Tricare’s “Network”. In order for the midwife to be in Tricare’s Network they need to apply (Tricare wants to make sure they are certified). They can do this by going to: http://www.humana-military.com/ and under provider they need to go to “quicklinks” and click on Join the Network. There they will submit their professional info to start the process…this could take a few months so have them do it ASAP.
To submit the claim in order to get reimbursed you have to submit the “beneficiary claim form” or have your provider/midwife submit Form 1500 for Providers. I’m going to try and submit the beneficiary claim form myself because my midwife can only submit after the baby is born but we want to be reimbursed sooner since we are paying up front and out of pocket. Beneficiary claim form can be mailed to: PO Box 7031 Camden, SC 29020.

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16 Suchada @ Mama Eve September 10, 2012

This applies only to Certified Nurse Midwives, who are regulated nationally, not Certified Professional Midwives, who are not regulated or legal in all 50 states. Great info for anyone who can find a CNM to do a homebirth, though! Thank you for sharing.

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17 Noel September 10, 2012

My midwife is a CPM and is recognized by Tricare…don’t know how but she is in their network. I will not ask questions but just submit the paperwork and see what happens. I suggest people give it a try, especially if you are choosing a natural birth and your midwife for all other reasons besides financial…obviously that’s important but not the most important factor :)

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18 Suchada @ Mama Eve September 10, 2012

That’s true — there’s no harm in submitting paperwork and seeing what happens. The worst they can do is say “no”.

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19 Danielle Jackson November 13, 2013

Hi, I’m about 5-6 weeks and am seeking a natural birth in this area. I live in Bishop, CA about a 2-3 hour drive away from Ridgecrest. Can you help me? Can you tell me who your midwife was? Is there anything in this area? Thank you so much for your help. It seems impossible finding these answers in such a rural area.

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