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Getting Your Homebirth Covered By An HMO
Complaint letter to the CA Department of Managed Healthcare Re: Blue Shield HMO
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California Department of Managed Health Care
980 Ninth St. Suite 500
Sacramento CA 95814
June 28, 2002

RE: Blue Shield’s Refusal To Provide A Covered Benefit

To whom it may concern,

I am a healthy pregnant woman and I wish to have a homebirth as is my legal right in the state of
California. I want to have a homebirth because of the decreased rate of interventions, birth
injuries, and infections (Please see medical research enclosed). And also due to the highly
personalized care that midwives provide. It is medically necessary for me to have a qualified
attendant to monitor me and my baby during labor and birth.

I read my evidence of coverage book seeking information on homebirth and midwifery.
According to the evidence of coverage book page 4 (copy enclosed) I was supposed to call the
health plan to confirm coverage of the services. I contacted my insurance company before I was
even pregnant to inquire about coverage. I was told:

“Professional services for maternity care provided by a Certified Nurse Midwife (CNM)
are a covered benefit at a birthing center, hospital, doctors office, clinic, or at home.”

-Read to me off of Blue Shield’s computer intranet over the phone by
customer service employees: Rae Anino & Jennifer Huff 1/11/02, Torwanda
Cammack 2/20/02, Tammy Bond 2/25/02 Sue Beuelson 3/4/02
Danielle 5/9/02 and Noel Neptune (customer service supervisor) 5/9/02

I tried for months to locate an in plan CNM with no help from Blue Shield (BS). Failing that, I
found a CNM on my own and started to pay for my prenatal care out of my own pocket.
Expecting that they would realize their mistake and authorize payment soon. I could have chosen
a Licensed Midwife (LM) at a significantly less cost than a CNM, but I did what BS wanted
because I believed what I had been told: “CNM’s were covered, LM’s were not”.

According to the evidence of coverage book page 4 (copy enclosed) “If no plan provider exists in
the network to provide the covered service (homebirth) then an out of network request will be
granted subject to the limitations and exclusions listed in the evidence of coverage book.” There
are NO plan providers that do homebirths. There are also NO limitations or exclusions related to
midwives or homebirth listed in the book. Yet, BS has refused to grant me this out of network
request.

I have read that California requires insurance companies to reimburse for licensed midwifery
service providers. But I am not a lawyer, I cannot find the law.

A little history....
On 2/28 Memorial Health Care IPA denied my out of network request (enclosed) on ridiculous
grounds. I wrote the medical director, Stanley Warner, of the IPA on 3/7 to try to get him to
reconsider, thinking my doctor’s secretary had improperly not specified the type of midwife
(CNM). I received absolutely no response.

On 3/7 I also filed a 30 day appeal. BS did not give me notice that my appeal had been received
within 4 days as is required by law. They also took more than 30 days to uphold the denial but on
completely different grounds. (see enclosed letter from Lisa Cummings). On 5/9/02 I was told by
one of Dr. Fass’ assistants that he had denied my appeal without reading my “complaint letter”.
My appeal was written in the form of a letter like this one.

I filed another appeal and made a presentation of my “case” before a panel of BS employees on
the 19th of June. I had been told that I would be given a panel of people not previously
connected with my case. But, when I arrived, Dr. Fass was on my panel. I did not think that was
a fair situation. At the meeting, a full 6 months after I started this process, BS gave me a list of
providers for Talbert Medical Group that included 3 CNM’s. Unfortunately, they only do
hospital births so that doesn’t help me at all. At the meeting, the panel members stipulated that
quality of care was not the issue, and that indeed homebirth with a qualified attendant is just as
safe if not more so than a hospital birth. So it seems, my original out of network request should
never have been denied in the first place. Out of network requests for this same situation have
been granted before by my health plan according to their very own employees and 2 letters I have
obtained from other women who had babies with midwives. There then was some discussion
about midwives not being “specialists”. On the Talbert Medical Group flyer they gave me,
CNM’s are listed under “Specialty Care”. The evidence of coverage book only says “plan
provider” not “physician with a specialty”. The fact remains, BS can’t find me anyone in plan to
do a homebirth.

I was told on the phone by a DMHC representative that if it is in the best interest of the patient
the DMHC can force an insurer to pay.” I cannot understand why a safer, legal, cheaper,
alternative care provider is not allowable. Clearly, it is in my best interest and the best interest of
my child to have midwifery care rather than medical management.

I ask the DMHC to please force BS to pay this small amount ( $3,800.00 ) rather than the much
greater cost of an unnecessary hospital birth. ($7,000-$10,000). If a complication would develop
I have always said I would use the plan hospitals and physicians so there would not be any extra
expense.

My midwife is also willing to answer any questions regarding her statistics or protocols etc.
Please contact me to explain the laws regarding this issue, as nothing I have been told makes any
sense. I am also willing to provide anything else you may need. Thank you.

Sincerely,

me


cc: Cherie Garcia (PCP)


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