Blue Shield HMO
Appeals and Grievances Department
PO Box 92945
Los Angeles CA 90009-2945

March 7, 2002


RE: Denial of out of network care request for maternity services provided by a CNM, for
me, wife of member (my hubby) subscriber #...

To Whom it May Concern,

It is my belief that I am being denied a covered benefit:

“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 your 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

According to the Blue Shield Access+ HMO Health Plan Member Bill of Rights Item
4 and Item 2,
I should have been given information about all health services available to me and “a clear
explanation of how to obtain them”, .

This has been sorely lacking. CNM coverage should be better advertised as available.
There is no mention of CNM care in the evidence of coverage book, yet I was assured
repeatedly that it is a covered benefit. When I asked where I could find a CNM I was told
by Jennifer Huff that she could not locate any because that category came up blank.
Torwanda Cammack told me that I would have to go to a medical group that employed
midwives, but she couldn’t tell me which groups had them. Sue Bewlson looked up nurse
practitioners for me in LA but was unable to direct me to any CNM’s. They had no other
suggestions for me.

The customer service at the Memorial Healthcare IPA was completely disorganized and
almost impossible to reach. The telephone system disconnects you, transfers you, says a
woman will answer in a few moments and then a man answers. I left a message for La
Ron at customer service and never received a call back.

I called every maternity hospital in my area seeking midwives to locate their offices. I
called most medical groups in my area also. I was unsuccessful in finding any “in plan”
CNM’s. I would like to know why they are not available.

I was told by Jennifer and Rae in the customer service dept. that to obtain CNM coverage
under the HMO plan I would have to submit a request for “out of network care” through
my personal care physician.

I was told by Tammy Bond to have my midwife call the authorization department at
800-213-3465 because my IPA would only refer to board certified OBGYN’s. My
midwife’s receptionist called and was unsuccessful. Cheryl at the authorization dept. told
her that she could not authorize anything that the IPA did not.

I then had my PCP submit the request for out of network CNM care for maternity
services. My request was denied by Dr. Stanley Warner, medical director of the IPA, for
“quality of care issues”. My response letter to him is attached.

I am trying to obtain the appropriate level of care for my circumstances.

CNM’s have better outcomes than OBGYN’s caring for healthy moms and babies with no
identified risk factors, regardless of the place of birth. If a complication should develop I
would use the plan physicians and hospitals.

It will save thousands of dollars to authorize me to see a midwife for all care.

My first birth with an OB in a hospital cost thousands, not including all my prenatal and
postpartum care. This birth should not exceed $4000.00 including, hydrotherapy during
labor, and all pre and post-partum care, a post partum home visit and use of the birth
center if I wish.
It perplexes me that Blue Shield would insist on spending thousands of dollars
more for more advanced medical care than I require, especially when it is against my
wishes.

I would like CNM’s to be welcomed in your HMO health plan.

Informed mothers such as myself believe in preventative care and the appropriate use of
technology. It is only reasonable that a midwife have a physician to consult with and refer
clients to if the need arises. CNM’s must have written agreements with their backup
physicians. Licensed midwives often have problems obtaining physicians to back them up.
I find that disgraceful. It appears that the medical profession simply wants to maintain
their monopoly on childbirth, which is now the number one cause for hospital admission in
California. The reason for excluding midwives cannot be a “quality of care issue”, as Dr.
Warner suggests, based on the literature and worldwide success of the midwifery model of
care. If I need to prove the quality of midwifery care I am prepared to do so. Please let
me know if you need this information.




Other out of network care providers have been approved in the past

Other out of network CNM’s have been approved in the past either as “alternative care
providers” or otherwise.


Midwives are a legal alternative

Midwifes are licensed by the state of California. I have been assured that CNM services
are a covered benefit and that is what I want. To say that I cannot have a CNM because
there isn’t one in a group in my area creates an artificial barrier. I have the same
premiums as the lucky women in an area with CNM’s “in-plan” and I want the same
coverage.

I have researched the safety of midwifery model of care and it is superior to that of an
OBGYN, in my situation. As I said above, if you wish more documentation of the safety
I will provide you with the medical literature references but I am trying to be succinct. I
do not intend to put anyone at risk and am willing to sign any waivers of legal liability etc.
that the health plan wishes. In the end the responsibility for my choices is my own.

I do not wish to delay my prenatal care any longer. I hope that we can come to an
acceptable resolution of this issue soon.


Sincerely,



me and my home phone #