Insurance Billing

The most common question we get is, "Will my insurance cover my birth?"
The question is simple and complex at the same time!


To start, it depends on the type of insurance policy you have.  


To make this easy lets eliminate those that do not cover; Kaiser, MediCal, any HMO or EPO policy, TriCare or any of the Covered California policies. What's left?


PPO Policies

Most PPO policies cover APM's services at the out-of-network rates as we are not contracted with any insurance companies.  Most often a GAP exception is available to be requested by either the insured (you) or the provider (us).  See below for GAP exception.


GAP Exception

A Gap exception (also referred to as a network deficiency, In-Network exception, out-of Network Exception, etc) is a request to honor a patient's in-network benefits, even though they are seeing an out-of-network provider because there is a GAP in the available providers.  If there are no contracted birth centers or midwives, typically within a 30-mile radius of your home, most PPO's will allow you to apply for a Gap exception and will pay the in-network rates for your care which typically include lower deductibles and higher percentage of payments. 


Billing

Ancient Paths Midwifery uses an outside Insurance Billing Service that specializes in holistic practitioners.  Only those utilizing insurance billing will pay for this service and there additional fees for this service.  If your very first pregnancy visit is at APM, we can do a test bill for that service.  Because maternity services are billed globally (meaning they are bundled with prenatal care, birth and postpartum care) we cannot bill insurance until the 6 week postpartum visit is completed.  


Reimbursement

When dealing with insurance of any kind, know that our birth package is priced to be paid in full before your birth and then we will bill your insurance after your 6 week postpartum visit.  The insurance company will reimburse you for any covered expenses. 


Different types of Insurance Policies

Preferred Provider Organizations (PPOs)

You can see "preferred" providers or "out-of-network" providers

  • A PPO has a network (or group) of preferred providers. You pay less if you go to these providers. Preferred providers are also called in-network providers and have special contracts with the insurance companies to accept predetermined rates.
  • With a PPO, you can go to a doctor or hospital that is not on the preferred provider list. This is called going out-of-network. However, you pay more to go out-of-network. The PPO pays less or nothing at all.  Most insurance companies include Midwifery care with a California Licensed Midwife in the OON care.

What are my costs if I have a PPO?

  • Cost can vary. It depends on the providers you go to. If you stay in the PPO's preferred provider network, your costs are less.
  • If you choose to go to a provider outside the PPO network, you pay much more. Before you see an out-of-network provider, check with your PPO to find out what is and what is not covered.

Exclusive Provider Organization (EPOs)

You must use providers in the EPO network.

  • Generally, you do not have to use a primary care doctor.
  • Most of the time, you do not need to get referrals to see specialists who are in-network.
  • EPOs can have many limits on the doctors or hospitals you can use. With an EPO, you can use the doctors and hospitals within the EPO's network. However, you cannot go outside the network for covered care.
  • If you do go out-of-network, your EPO will not pay for any services. The only exception is if you have an emergency or urgent care situation - so midwifery care is not covered by an EPO.

Health Maintenance Organizations (HMOs)

You must use providers in the HMO network.

  • Usually, you must have a primary care doctor. This doctor provides your basic care and makes referrals to specialists.
  • If you see a provider outside of your HMO's network, they will not pay for those services (except in the case of emergency and urgent care).
  • The doctors and other providers may be employees of the HMO or they may have contracts with the HMO.
  • Some HMO policies do include midwifery care but it's our experience there has never been a Licensed Midwife contracted with an HMO to provide this coverage.  They will tell you that you can apply for this through a referral and then it goes for review.  THEY WILL NEVER ACTUALLY APPROVE IT!   It's important you understand that you can try but it's % 99.999 that they will end up denying the coverage for anyone not contracted.  
  • Midwives cannot become contracted with the HMO's.



For a list of Insurance Related acronyms and terms, click here.