Credit: Sandor Weisz on Flickr, under Creative Commons

(WOMENSENEWS)–New York State’s largest insurance plan used to pay some of the top fees in the country for midwifery services contracted through Medicaid, the federal public insurance program for low-income Americans. 

But in March, the plan, HIP, lowered midwife payment through Medicaid for homebirths to $1,700 from $7,000. Now all midwives are being paid this flat rate, whether deliveries take place at home or in a hospital.

“The only reason given from the insurance company for the pay cut was so they could reapportion how payments were made because of the new health care system,” said Memaniye Cinque, who practices at Dyekora Sumda Midwifery and Nutrition Services in Brooklyn, N.Y., where over 70 percent of her clients pay through Medicaid. “The decrease is a big step backwards and deserving of attention on a larger scale not only to increase the amount of reimbursement we receive, but also so that the increase happens not just in one company but across the board.”

About half of all U.S. births are covered by Medicaid, which means decisions made about midwifery here could ripple through plans in the public-private health insurance system that launched in 25 states and the District of Columbia. That system is managed under a mix of state and federal policies and leaves midwives along with many others in the health care field feeling their way forward through the gray areas of the law.

A few states and U.S. territories have not yet filed the necessary state payment plans to include midwifery coverage under Medicaid. That list includes Alaska, Hawaii, Oklahoma, Wisconsin and the Virgin Islands.

According to the Centers for Medicare and Medicaid Services, six other states currently have payment plans under review: Colorado, Florida, Illinois, New York, Ohio and Pennsylvania.

Many states are still getting payment plans approved by the Centers for Medicare and Medicaid Services because they lack clear implementation rules and regulations, Jill Alliman, chair of the American Association of Birth Centers’ Legislation Committee, based in Perkiomenville, Penn., said in a phone interview.

Private Insurers May Follow 

If Medicaid lowers payments, organizations such as New York City’s Choices in Childbirth are concerned that private insurers will follow suit. Although the law requires that marketplace providers offer maternity services as 1 of 10 essential health benefits, there is no language specifying which maternity services must be covered.

And while the Affordable Care Act says health plans can’t discriminate against an individual provider, it does not require plans to accept all types of providers into a network.

That also casts a cloud over freestanding birth centers, where about 90 percent of births are attended by midwives, including certified nurse-midwives and certified professional midwives. In a breakthrough, Medicaid began covering these centers in 2010 but states’ response was roiled by the passage of the Affordable Care Act in the same year.

“Birthing centers started being covered under Medicaid at the same time the Affordable Care Act was passed,” said the Birth Centers’ Alliman. “However, since the Affordable Care Act doesn’t specify birth center coverage, some states may not have changed their Medicaid policies. Strengthening the language of the Affordable Care Act to include birth centers would make a tremendous difference in making them available to more women.”

In Florida, payment plans have been denied because payment for midwives and birthing facilities were lumped together, added Alliman. In some other states, money that had previously been allocated for paying midwives was being split between paying midwives who bill independently and paying birth centers that employ midwives.

Assessing Marketplace Plans

With no data about whether most marketplace plans are covering midwife services and freestanding birth centers, the American College of Nurse Midwives is currently assessing what maternity services are offered under all 277 marketplace plans, including midwife services and birthing centers.

If it is found that in a given state there is very limited coverage of birth center and/or midwifery services, this language could be used as the basis of a complaint to the state, or federal government, in the case of federally facilitated marketplaces, according to the American College of Nurse Midwives.

As the Affordable Care Act spreads uncertainty, advocates say it’s important to beat the drum about midwifery’s cost savings.

“We need to make sure policymakers and health insurers know about the benefits midwives provide,” said Jesse Bushman, director of advocacy and government affairs at the American College of Nurse Midwives, based in Silver Spring, Md., in a recent interview. “If marketplace plans could realize that these services provide low-cost, high quality care that keeps insurance costs down, more insurers would include them.”

Midwife births are lower cost because they are less likely to involve Cesarean sections. Just 6 percent of the 15,000 births performed by midwives were by C-section, compared to the U.S. average of 33 percent, finds a 2013 study published in the Journal of Midwifery and Women’s Health. C-section births cost nearly twice as much as vaginal births.

If U.S. C-section rates decreased to the World Health Organization’s recommendation of 15 percent, maternity costs would drop by $5 billion. In 2012, almost 8 percent of U.S. births were attended by certified nurse midwives, according to the National Center for Health Statistics.