❓How does medical insurance work with midwifery care?

All insurance plans have in-network benefits, but not all have out-of-network benefits. Midwives who are in-network have a contract with the insurance company, and each service has a specific agreed upon rate.

If your midwife is out-of-network, she does not have a contract. That means she sets her own rates for the care she provides, and your insurance company may or may not reimburse you depending on your plan.

If your plan does have out-of-network benefits, your midwifery care can be applied to your out-of-network deductible and out-of-pocket maximum. This can lead to partial reimbursement after those amounts are met.

❓ what is a superbill/itemized statement?

A superbill is a detailed, itemized statement of the services your midwife provided. You can submit it directly to your insurance company for potential reimbursement.

I prepare superbills specifically for home birth and birth center care. They include the proper codes and information insurance companies require.

❓ I’ve met my in-network deductible. Does that count toward my out-of-network deductible?

Usually not. Most insurance plans have separate deductibles for in-network and out-of-network care. Even if your in-network deductible is fully met, you’ll likely need to start over with your out-of-network deductible.

❓My midwife is out-of-network with my insurance company, can i still submit an itemized statement?

Yes, if your insurance plan has out-of-network benefits and covers midwifery care you should be able to submit an itemized statement.

❓How does my insurance company decide how much to reimburse?

Insurance companies use something called the Usual, Customary, and Reasonable (UCR) rate. This is the amount they believe is fair for a given service in your area even if your midwife charges more.

📌 Example:

• Your midwife performs an ultrasound and charges $350.

• Your insurance’s UCR rate for that service is $200.

• The $200 goes toward your out-of-network deductible and possibly coinsurance.

• You are still responsible for paying the full $350 to your midwife.

❓Medical insurance is confusing how can you simplify it?

Definitely. Let’s simplify the key parts of your out-of-network coverage:

• Deductible = What you must pay before insurance helps cover anything.

• Coinsurance = The percentage of the bill you split with your insurance after the deductible is met.

  Example: If your coinsurance is 80/20, your insurance pays 80%, you pay 20%.

• Out-of-pocket maximum = The most you’ll pay before insurance covers 100% of covered services.

💡 Helpful Tip:
These apply to amounts the insurance recognizes (usually the UCR, not the full amount your midwife charges).

❓I submitted my superbill. Why didn’t I get reimbursed?

It can be frustrating and here are the most common reasons why:

• Your deductible hasn’t been met yet.

  Even if services were processed, if the UCR rate was less than your deductible, you won’t receive reimbursement.

• The insurance company missed something.

  They may not have processed the statement correctly or left out important codes.
  👉 Send me the Explanation of Benefits (EOB) you received. I’ll review it and help you respond to your insurance.

• Your coverage wasn’t active during the dates of care.

• Your benefits changed or reset with a new coverage year.