Anonymous submission, Oregon
Licensed Direct Entry Midwife (After Section 2706 went into effect: Jan 1, 2014)
INSURER(S) / Agency :
(Note: This account is drawn from conversations and emails with the patient who preferred to submit anonymously.)
When she was 3-4 months pregnant, the patient changed jobs and soon qualified for maternity coverage under her employer’s plan. She had been working with a licensed direct entry midwife (LDM), who is licensed in Oregon to attend home births and supervise labor and pre-natal postpartum care.
The patient was not aware that her insurance company covered home births. While reading through a Facebook forum for expecting mothers, she learned about the provider non-discrimination clause of the Affordable Care Act: Section 2706. Another person on the forum complained about non-coverage for home births even though that person’s insurance company stated that it was covered.
The patient then contacted her insurance company to learn that in fact home births were covered but only when attended by a Certified Nurse Midwife (CNM) or an OB-GYN MD (so her LMD was not covered).
She then studied the provisions of Sec 2706 and came to the conclusion that they applied in her case (because her LDM is licensed in the state). She took her case to her employer who then requested coverage from the insurance company on her behalf. The company responded by repeating its position that the only type of midwives whose services are covered for home birth are CNMs. It also asserted that its plan was not out of compliance with Sec 2706, and that the company was not obliged to contract with certain providers.
The patient then contacted the state of Oregon Insurance Division to see if she had any recourse. She asked if insurance companies could independently interpret Sec 2706, or if a mechanism existed to ensure compliance. A representative said that the Division was responsible for oversight on questions like hers on insurer compliance with coverage rules.
At the suggestion of the representative, the patient filed a complaint through the department, which sent the complaint to the company. Soon thereafter the insurance division advised her by letter that there were no grounds for state enforcement in her case. The letter reiterated the insurer’s position that CNMs are the only midwives reimbursed for assisting at home births. It also asserted that CNMs are a different category of provider than LDMs.
In early September 2015, the patient filed a formal appeal with her insurer. In the appeal she emphasized that she personally had called each of the Certified Nurse Midwives on a list provided to her by the company itself. None provided home birth services. She also noted that this unavailability of CNMs and LDMs — even on an out-of-network basis – left her without coverage for the midwifery services she desired and expected; she also suggested the company was not adhering to network adequacy rules.
The patient forwarded to the Insurance Division the FAQ produced by IHPC consultant Deborah Senn. (See below)
Submitted: Sept. 15, 2015
 – In May 2015 Oregon passed its own version of Section 2706, HB 2468, which was signed by the governor. Its rules are being developed at this writing and will not take effect until 2017. (Oregon enacts non-discrimination legislation.)
 – Because both are licensed to attend home births in Oregon “provider category” makes no difference under Section 2706.
 – “Network adequacy” is a long-standing rule for health providers meant to ensure that the residents of a geographic area have access to sufficient numbers of various types providers: primary care, orthopedic, ENT, etc.
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