MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

Will PEBB restore access to licensed homebirth midwives?

Next Tuesday (April 20th), the Oregon Public Employees Benefits Board (PEBB) will discuss and, hopefully, restore its members’ access to licensed direct-entry midwives (LDMs). PEBB Members for Maternity Care Choice (members) will be there to continue months-long efforts to have PEBB direct Providence Health Plans to properly process claims for LDM reimbursement. The coalition’s online petition, with more than 470 signatures, enjoys broad-based, statewide support among PEBB members. Both the Oregon State University and the University of Oregon Presidents support restoring access to LDMs.

For background read my first and second posts. Click here for a guide to midwifery credentials and terms in Oregon.

Pregnant women caught up in PEBB’s procedural gaffe

In 2009, PEBB announced it would self-insure with Providence as the plan administrator. Many PEBB members planning or desiring coverage for LDMs asked for and received repeated assurances of uninterrupted access. PEBB members using LDMs are a proactive group. For more than a decade under PEBB BlueCross BlueShield, members enjoyed access to LDM-attended homebirth. In most of the state, LDMs are the only maternity care providers offering homebirth services. Because insurance coverage for this option is not the norm, members favoring this choice were motivated to double- and triple-check PEBB’s assurances of “no change” as it announced plans to self-insure. PEBB Q&A sessions, email exchanges and close readings of the draft 2010 handbook in September indicated LDMs would, indeed, continue to be covered as an out-of-network option at 70% reimbursement.

During the fall 2009 open enrollment, many members planning for or around current pregnancies made decisions regarding flexible savings accounts predicated on LDM access. By the end of 2009, as some members prepared to submit claims to Providence, they were told this benefit choice was excluded and claims would be rejected.

Members were referred to the 2010 handbook issued in January that excludes the services of direct entry and lay midwives. This language was not included in the draft handbook. Then in January 2010, members received PEBB’s newsletter with the following “fast fact:”

  • Direct-entry midwives are not listed as providers.

Clearly, PEBB staff and Providence believe the 2010 handbook and newsletter bar coverage for LDMs. This is incorrect – neither the exclusion nor the “fast fact” pertain to licensed direct-entry midwives. LDMs fully meet current definitions of practitioner and provider in the PEBB handbook and PEBB-Providence contract. In other words, PEBB staff and Providence employees are misinterpreting these governing documents and, as a result, erroneously rejecting legitimate claims. An explanation for this about-face has yet to be provided, although as of its last meeting PEBB directed staff to provide one in writing.

PEBB documents cover LDMs

The terms “qualified practitioner” and “qualified provider” are used in the 2010 handbook and in the PEBB-Providence contract. LDMs meet the definitions in each document.

Starting with the 2010 handbook definition on page 76:

Qualified Practitioner

Qualified Practitioner means a physician, women’s health care provider, nurse practitioner, certified nurse midwife, clinical social worker, physician assistant, psychologist, dentist, podiatrist, acupuncturist, naturopath, chiropractor, audiologist, Christian Science practitioner, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license.

The Oregon Health Licensing Agency licenses LDMs. Within their scope of practice, LDMs provide prenatal, intrapartum (birth) and postpartum care. They are trained to screen for and identify risk factors falling outside their scope of practice. When necessary, they advise and help transition women into medical care.

On page 43, the PEBB handbook limits coverage for homebirth services to those provided by qualified providers. Because LDMs meet the above definition of “qualified practitioner,” they should also be viewed as a “qualified provider” of homebirth services.

Exclusions that apply to Reproductive Services:

  • All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services;
  • Condoms and other over-the-counter birth control products; and
  • Home births and all related Services, except Services provided by a Qualified Provider.

Finally, LDMs meet the definition of provider in the PEBB-Providence contract on page 37:

“Provider means a health care practitioner or facility that is validly licensed by the appropriate state agency to diagnose or treat health care conditions and is providing services within the scope of that license.”

PEBB should process claims and increase transparency

PEBB, not Providence, determines what is and what is not covered and at what level. During the transition to self-insure, PEBB and Providence employees may have been unfamiliar with the LDM choice in maternity benefit. There have been other oversights and they are being resolved. Upon learning of unintended changes in coverage for breast pumps or of a failure to recognize naturopaths as a type of primary care physician, PEBB has directed Providence to restore coverage.

Restoring coverage for LDMs is no different. It requires that PEBB see the issue for what it is – a procedural gaffe. Accordingly, it should direct Providence to correctly interpret governing documents and process LDM claims. This can be done at the April 20th meeting.

PEBB should take the additional step of increasing transparency within governing documents by specifically naming LDMs as qualified practitioners who are qualified providers.

LDM access is a win-win scenario

Ensuring proper processing of claims and tightening language will align PEBB with its governing Vision and Key Components by prioritizing transparency, cost effectiveness, evidence-based care rooted in informed choice and excellent outcomes. Subject-area expert Dr. Melissa Cheyney speaks to this:

“There’s a common misconception in the U.S. that the hospital is the safest place to give birth,” she said. “This is certainly true for higher risk women. But for low-risk women there are now 33 studies that demonstrate that with a trained care provider, when a complication arises, and the home birth is planned, that home birth is as safe as or safer than the hospital. It also results in enormous cost savings, lower rates of intervention, higher rates of psychosocial outcomes that are considered positive like prolonged breastfeeding and high satisfaction rates for the mother. So these women are actually practicing evidence-based maternity care.”

In other words, LDM-assisted homebirth is a maternity model of care predicated on health and wellbeing, the very essence of preventive care that PEBB is striving to encourage among all members.

Correcting course is also a financial win-win scenario for PEBB and its members. Women and families opting for homebirth with an LDM will generate significantly reduced claims. Roughly speaking, LDM maternity care runs approximately $3,000, meaning PEBB reimburses $2100. Hospital-based maternity care including uncomplicated birth costs approximately $16,000. In the case of planned cesarean section, insurers regularly pay more than $20,000. Coalition members project annual savings for PEBB ranging between $265,000 and $560,000.

In closing….

Regardless of the reason for selecting LDM-assisted homebirth, women who choose this option avoid the routine use of intervention and cesarean surgery to manage low-risk, normal labor. If PEBB fails to remove bureaucratic barriers, women unable to pay out of pocket will be forced into the hospital. Hospitals are struggling and mostly failing to acknowledge and correct practices fueling the nation’s cesarean epidemic and astonishingly poor track record for supporting women and babies to breastfeed. Withholding LDM-care from those who prefer it is a losing proposition for women, families and PEBB.

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7 responses to “Will PEBB restore access to licensed homebirth midwives?

  1. Amanda April 15, 2010 at 4:22 pm

    Excellent post! I have really been enjoying this blog – you provide such excellent information. Thank you for your efforts!

    I wanted to add that the exclusion of LDMs also effectively eliminates access to birthing in birth centers (free-standing or attached to a hospital), unless you are in one of the few areas in the state that has CNMs on staff. So this gaffe by PEBB not only eliminates the home birth option, but for the majority of women, the birth center option is also gone. This forces women to use hospital-based maternity care. We should have the right to choose where we give birth and not be penalized financially by that decision!

    I’ll be at the meeting on April 20th!

  2. Steven Wightman, CFP April 18, 2010 at 7:05 pm

    Natural birthing’s time has come. Families working with medical care givers should be able to make their own choices about what will happen to their bodies and what’s best for them. Insurance companies should not be making this decision. If insurance whether, self insured or commercial, really wants to cut costs and improve care, then natural birthing is the place to begin. Here, everyone except hospitals wins. Insurance pays far less and the health outcome is improved to mother and baby.
    It’s time for insurance companies to walk their talk and do what’s right, not what’s profitable for hospitals who are in a MacDonald’s like business of packaging of birthing care for mass consumption. How can we go forward continually looking in the rear-view mirror? When it comes to birthing, that’s how we’ve practiced medicine since Julius Caesar. Getting back to natural birthing is good for mom and baby, good for a sustainable and healthy, society – not to mention our planet. Freedom of choice and natural birthing makes a lot of sense and it has my vote!

  3. Melody March 6, 2012 at 10:16 pm

    I was wondering where I can find current info on PEBB coverage for home birth. Do I call someone at PEBB or providence insurance? If it is available I would like to change my insurance plan next open enrollment period to cover a home birth for the next little one.

    • motherbabynetwork March 7, 2012 at 4:37 am

      Hi Melody,

      Licensed direct-entry midwives or LDMs (home birth providers) are currently covered at 70% on the PEBB Statewide Plan. None of the other insurance plans offered through PEBB currently provide this benefit. At next open enrollment, be sure to confirm this benefit still exists (check the 2013 handbook) when making a decision. When specifying coverage, be sure to distinguish between LDM (home birth) and midwifery which can mistaking be understood to refer only to certified nurse midwives or CNMs. Oregon CNMs practice almost exclusively in birth center and hospital settings. I think there might be a few who are still doing home birth but not in the Eugene / Springfield areas, as far as I know.

      I have heard folks have had difficulty getting coverage for supplies or newborn screening tests which I believe are covered. So be well informed of what is covered in advance and monitor and insist, if necessary.

      Also, you might consider joining the PEBB-members list serve for folks interested in retaining and monitoring this coverage:
      http://lists.oregonstate.edu/mailman/subscribe/pebb_members_for_maternity_care_choice

      Best of luck and thanks for reading my blog.
      Katharine

      • Sarah September 14, 2012 at 12:49 am

        I’m signing up for insurance right now, and the only thing I found was that LDM’s were excluded “except as described in OAR 332-025-0021 and following our receipt of the LDEM disclosure statement”.

        Does that mean that they actually aren’t excluded unless they receive their statement? I’m new to Oregon and it’s such a pain figuring all of this out! Your blog has been super helpful!

        Florida where we had our two children has backwards laws in many ways, but at least they can’t do anything that would exclude letting a woman birth where she wants 😦

  4. Sarah September 14, 2012 at 12:50 am

    Oh, and sorry- I meant to say that I found that in the PEBB handbook for 2012!

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