Insurance coverage for maternity care is required in most individual and small group plans under the federal health law, extending such coverage to plans where it used to be rare. But for women who are interested in services provided by midwives and birthing centers, there are no coverage guarantees, despite the law’s provisions that prohibit insurers from discriminating against licensed medical providers.

Most women give birth in hospitals and are attended by obstetricians, but a growing number choose to deliver their babies at birth centers. The centers, typically staffed by midwives, offer women who are at low risk for complications an alternative to traditional hospital labor and delivery, eschewing common medical interventions such as drugs to induce labor, among other things.

Under the health law, Medicaid programs are required to cover the services of licensed freestanding birth centers. Coverage of midwifery services had earlier been mandated by federal law.

“Birth centers and certified nurse-midwives have a good record of safety and patient satisfaction and birth outcomes,” said Cynthia Pellegrini, senior vice president for public policy and government affairs at the March of Dimes.

Birth centers also are significantly less expensive than hospitals. The average hospital charge for a vaginal birth without complications was $10,166 in 2010, compared to $2,277 for a birth center, according to data from the Agency for Healthcare Research and Quality and the American Association of Birth Centers.

Some advocates predict coverage of birth centers in private insurance plans will become routine now that Medicaid, which pays for roughly 50 percent of all births in the United States, has embraced their use. But at this time, coverage for birth centers and for midwives is less predictable in private insurance plans.

When Stephanie and Sean Taylor learned they were pregnant last July, Stephanie, 30, initially planned to use an ob/gyn and deliver in a hospital near the couple’s home in Rancho Santa Margarita, Calif. But after visiting her doctor a few times, she began to have misgivings about the practice’s routine use of ultrasounds, among other things, during her visits.

“I wondered, is this really necessary?” Stephanie said. “I’m a really healthy person, and I’m not high risk. I started to question all of this.”

The couple’s Blue Shield of California HMO plan doesn’t have midwives or birth centers available in the couple’s network. When Stephanie asked her ob/gyn to approve a request for her to use a non-network nurse midwife, he declined, as did Blue Shield.
In its denial letter, Blue Shield said her plan allows for the coverage of midwife services. But it noted since there are none available in her medical group, she was limited to using any participating obstetrician.

“If someone can get better, less expensive care, why are their hands tied?” Stephanie said. “People should have the right to choose what’s best for them.”

She and her husband decided to pay the $5,500 charge for the midwife and birth center on their own. Their baby is due in April.

Blue Shield of California declined to discuss the details of Taylor’s case, but in an email response, the company said generally people insured through an employer-provided HMO “must access medical services from providers within the plan network in order to be covered.”

Under the health law, maternity and newborn care is one of the 10 essential health benefits that must be covered in individual and small group plans, unless they have grandfathered status. But the law doesn’t require specific types of providers be covered, said Dania Palanker, senior counsel at the National Women’s Law Center.
Starting this year, health plans are prohibited from discriminating against licensed or certified health care providers who want to participate in their networks. However, the law says insurers aren’t required to contract with any particular provider.

Midwifery and birth center advocates say they’re uncertain how the nondiscrimination provisions will be applied or enforced, and the Department of Labor said it’s not issuing any further guidance.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research organization not affiliated with Kaiser Permanente.

By Michelle Andrews Kaiser Health News