With third-party reimbursement for childbirth education, one of the biggest barriers that exists in policy discussions is that not all stakeholders, including the educators themselves, understand what the current system is. The system is intricate and always changing, but on the surface, it boils down to three things: What is covered, who can render services, and how much are they paid.
Part of our existing insurance system is controlled by the federal government. A good example of this would be how the Affordable Care Act mandated that breast pumps and breast-feeding support was a covered benefit. Otherwise, most healthcare regulation decisions are made on the state level. This is where childbirth education falls right now: the coverage varies from state to state, and can change as new statutes are passed.
In Minnesota, childbirth education is considered a mandatory covered service by the Department of Human Services for residents who have coverage through Medical Assistance programs. Strangely, newborn care education is not considered essential, so as a standalone class it is not a covered service, but birth classes that include this information can be billed to insurance. Residents who are on Medical Assistance are either enrolled directly through the state’s Medical Assistance or MinnesotaCare coverage. Some of the plans are managed though the state itself, but most are have PMAPs (Minnesota Prepaid Medical Assistance Project plans) that are administered through Managed Care Organizations.
So then, in Minnesota, not all employer-based insurance plans or plans purchased by individuals have the same coverage parameters. So while some do reimburse providers for in-person group classes, other health plans consider access to online information or sending pregnant patients a book as an acceptable way to deliver childbirth “education”.
Most state’s health departments then decide who can provide services– what kind of credentials they need to have and if they have to bill under a supervising provider. Again, in Minnesota, I have to operate under a “supervising provider” as an LCCE. It usually doesn’t take much digging, but each state is different, so what applies here may be different, but states are currently in charge of the “Who.”
As for the how much…that gets really complicated. Reimbursement rates for Medical Assistance services are set at the state level, and many of the rates haven’t been adjusted for inflation in 10-20 years. Employer-based plans set their own reimbursement rates, and those rates can vary even within the same insurer as determined by what the employer has negotiated. For example, you could have Blue Cross Blue Shield insurance and the contracts would say that if the provider bills the insurer for a procedure at $150 and the contractual obligation would be to only reimburse $110 of that money; Somebody else with a Blue Cross Blue Shield insurance plan with a different employer might have that same service reimbursed at $97 when it was billed for $150. And then you have some other insurers who would take that $150 that was billed and only reimburse $35.
Not just anybody can bill insurance though, even if you are providing care within the state’s parameters. If you are not contracted with an organization as a provider, then anything billed would be out of network and would be subject to reimbursement rates set by the plan for out of network reimbursement. This really only applies to employer-based or individual plans; I’ve yet to find a state that allows billing reimbursement for out of network providers.
Hopefully this brief explanation helps you understand the very basics of third-party reimbursement for childbirth education as it exists today. If childbirth education is covered depends on which state you are in. Who can provide that childbirth education in a way that’s billable is also up to each state. The how much is something spelled out by each plan coverage. It’s not an ideal situation in the slightest; however, anyone who wants to fix something first needs to understand how it works, otherwise it’s very likely any attempts to fix it will break it.
I am hosting a series of workshops, first for doulas locally, later for birth professionals via webinar. If you’d like to notified of upcoming dates, sign up for the professional development newsletter below.