Understanding Out-of-Network Benefits: What You Need to Know for Midwifery Care)
When you're choosing someone to support you through your pregnancy, birth, and beyond it is about trust, connection, and feeling supported in your choices. For many families, this means choosing a midwife that may be out-of-network.
The good news? If you have the right type of insurance, out-of-network midwifery care may still be reimbursable.
In-Network vs. Out-of-Network: What’s the Difference?
In-network midwives or providers have a contract with your insurance company, so their services are billed at pre-negotiated rates.
Out-of-network midwives or providers do not have that contract. But that doesn't mean your care won’t be covered, it just works a little differently.
Do You Have Out-of-Network Benefits?
If your insurance is a PPO (Preferred Provider Organization), you likely do have out-of-network benefits, which means your insurance can reimburse part of your care with a midwife who is not in-network.
If you have an HMO (Health Maintenance Organization) or EPO (Exclusive Provider Organization), out-of-network coverage is not included.
An out-of-network deductible is the amount of money you have to pay for health care services prior to your insurance company beginning to pay any portion of your medical care.
Insurance company out of network reimbursement rates are determined by what they consider “usual, reasonable and customary”. These rates are set by each insurance plan. However, the rate set for each service may be less than the billed charge from your out-of-network provider. You are responsible for any charges over the set rate by your insurance company.
For example: You have a medical visit with an out-of-network provider and the medical visit is coded appropriately for the type of visit it is (well visit, sick visit, etc.). This particular visit on this day is a sick visit. The out-of-network provider codes the visit as a sick visit and submits it to your insurance in the amount of $400.00. The “usual, reasonable and customary” rate for a sick visit for using an out of network provider for this particular insurance plan is $150.00. Your insurance processes the claim and deducts the amount of the “usual, reasonable and customary” from your benefit amounts (deductible, out of pocket max). You are still responsible for the amount of $400.00 since your out of network provider’s fee is $400.00.
How does this visit effect your deductible?
Let’s say for example you have an out-of-network deductible of $2,000.00. The sick visit that you paid for was $400.00 from your out of network provider. $150.00 of the $400.00 will go towards your out-of-network deductible (because that is the “usual, reasonable, and customary” allowed amount for an out of network sick visit with your insurance plan . This amount will go towards meeting some of your deductible in the amount of $150.00. Now, your remaining out-of-network deductible is $1,850.00. You will have to meet the rest of this deductible before your insurance starts to reimburse for any portion of your medical care.
The key here is that no matter what your out of network provider submits as the fee for service, your insurance plan will only process their allowed amount towards your benefits even if that amount is less than the billed charges.
Check back for more blogs about insurance including: out-of-network deductibles, coinsurance, copays, out of pocket maximums, maternity care, Medicaid, Baby care, Birth Center benefits and more.