FOUR SOURCES OF COVERAGE
Benefits differ across companies and plans. A single insurance company will sell a variety of plans at different price points, each with it’s own level of benefits. That’s why knowing where the coverage is from is key to understanding the level of coverage you have and what are your options.
We are also aware that your midwife is likely out of network with your insurance plan. We’ll come back to this. First, let’s take a look at the four main sources of coverage.
1. EMPLOYER
OUT-OF-NETWORK PLANS COVER AN AVERAGE OF 2/3 OF YOUR MIDWIFE’S FEE
If you decide to use out-of-network benefits, reimbursement can vary widely. Your deductible and coinsurance, along with your plan’s allowable amount for services you receive heavily influence it. Some plans will offer “in-network exceptions” to out-of-network providers if the network does not have comparable midwives. See our FAQs for more.
PLANS LIMITED TO OUT-OF-NETWORK BENEFITS (“IF YOU HAVE THEM, YOU MUST USE THEM”): AETNA, CIGNA, EMBLEM HEALTH, EMPIRE, AND UNITED HEALTHCARE
(In our experience these plans tend not to grant In-Network Exceptions)
These plans tend to have out of net benefits for you to use at will. In-network exceptions may be available as a means to improve the coverage level but this is a complex issue and one we work with you to assess when you sign up with one of our midwifery clients.
Overall, if your midwife is out of network, and your policy includes out of network benefits, this is the coverage we will focus on. You should expect out of pocket costs that vary based on your deductible, coinsurance and any portion of the charges not covered by your plan.
2. THE MARKETPLACE
NO OUT-OF-NETWORK BENEFITS; NO SET PAY RATE; IN-NETWORK EXCEPTIONS REQUIRED
If your plan comes from the Marketplace, it does not have out of network benefits. But we are often able to obtain “in-network exceptions” if your midwife is out of network.
If newly enrolling for coverage through the marketplace, note that you will be paying the amount of your deductibles and coinsurance to your midwife. Lower tier plans have higher deductibles for you to cover before your plan benefits kick in and begin to pay for services.
See our FAQs for more
PLANS FROM THE MARKETPLACE: FIDELIS, METROPLUS, MVP, UNITED, OXFORD, AND OSCAR
(These plans will generally consider a request for an In-Network Exception. Its important to note that if your midwife is not in network the request is not a guarantee of approval. These plans can change their policies for approving out of network services at any time.)
3. MEDICAID
NO OUT-OF-NETWORK BENEFITS; NO PATIENT RESPONSIBILITY; IN-NETWORK EXCEPTIONS REQUIRED
Medicaid plans are designed without OON benefits – this is to prevent costs for non-covered services from landing in your lap. Most Medicaid coverage is managed by an insurance plan. Ask your midwife is she is in network with your plan. If not, we may be able to obtain an in-network exception to get her services covered. Some plans are more open to this process than others. See our FAQs for more.
COMMON MEDICAID PLANS: FIDELIS, HUDSON HEALTH PLAN, UNITED HEALTHCARE COMMUNITY PLAN, AND METROPLUS, HEALTHFIRST
(These plans will generally consider a request for an In-Network Exception. Its important to note that if your midwife is not in network the request is not a guarantee of approval. These plans can change their policies for approving out of network services at any time.)
4. OFF THE EXCHANGE / OTHER
FUNCTIONS LIKE EMPLOYER-BASED PLANS: OUT OF NETWORK PAYS 1/3 OF MIDWIFE’S FEE
These out-of-state based plans tend to include out of network benefits that can readily be used. Most military based plans also have out of network benefits or will work with your midwife to grant an in-network exception. If using out-of-network benefits, reimbursement is commonly one to two-thirds your midwife’s fee.
These plans come from specialty groups and often from outside New York and it can be difficult to get an In-Network Exception.
See our FAQs for more.
COMMON PLANS: ANTHEM, BCBS, CHRISTIAN MEDISHARE, MPI, NATIONAL HEALTH ADMINISTRATORS, TRICARE, US FAMILY HEALTH PLAN