Medicare and Medicaid Coverage of CPM Services
By Susan M. Jenkins, J.D.©

As Certified Professional Midwives achieve recognition of the CPM credential in state after state, the inevitable next step for many is third-party payment for services – especially government health care plans. The health care system in this country is presently a varied hodge-podge of government and private payment mechanisms, ranging from federal government plans such as Medicare, Medicaid, Tricare, and the Federal Employees Health Benefit Plan (FEHBP) – to private managed care to traditional insurance. From the perspective of CPMs and their clients, however, this vast and dysfunctional array of health payment mechanisms has one overriding attribute in common – for the most part, they do not cover home birth or the services of CPMs and, if they do cover birthing center services, they do not pay the facility fee. For many consumers, non-coverage of a service, however much that service may be desired, may result in lack of access. CPMs and state midwifery associations are repeatedly frustrated by the stone walls they encounter when they seek participating provider status, either from private managed care or state Medicaid plans.

Getting paid for the services one provides is a hallmark of professionalism – not the only hallmark but, nevertheless, an important indicator that a profession has been recognized as a significant component of the health care system. The American Public Health Association (“APHA”) has taken the position that government, as well as private, insurance plans should “eliminate barriers to reimbursement and equitable payment of direct-entry midwifery services.”1 NACPM, as the national professional association for CPMs, has decided to accept the challenge of overcoming these barriers and securing participant status for CPMs, concentrating first on the federal Medicaid and Medicare plans. As an attorney who has represented midwives and other health professionals for the last 25 years, I applaud NACPM for rising to this challenge at this time.

Why start with the federal government? In most states, Medicaid pays relatively little for prenatal and birthing services, compared to many private insurers, and relatively few Medicare patients seek home birth. The reason is simple: Medicare is considered the “gold standard” in the world of health insurance and managed care, setting the standard for which services and which providers will be covered. If you are excluded from these programs, success with the private payors is unlikely. Some CPMs, however, may not be as familiar with these federal plans as they are with private managed care.

Basically, Medicare pays for health care services and facility charges for senior citizens and persons with certain disabilities. This affects midwives because disabled women have babies, and use Medicare as their payment mechanism. Medicaid is a combined federal-state plan that pays for health care services for low-income persons, primarily women and children. Tricare is the health care program for military dependents as well as retired veterans and their spouses, while the FEHBP, as its name implies, provides health insurance options for federal government employees. Of these, Medicaid is probably the most significant source of health care payment for women and families. A 2002 study by the Kaiser Family Foundation found that, in some states, as many as 48% of births are paid for through Medicaid. Federal employees and their families, as well as military dependents, are also a significant pool of potential clients for midwives. Private insurers and managed care plans who participate in the FEHBP program must provide the full scope of coverage mandated by the federal government.

Each of these federal programs presently pays for services provided by certified nurse-midwives (CNMs). In fact, both Medicare and state Medicaid plans are mandated by federal law to include the services of CNMs and most state plans have done so since 1988, when the federal Social Security Act was amended to add CNMs to Medicare and Medicaid. Initially, federal law only required state Medicaid plans to cover prenatal care, birthing services, and post-partum care but, in 1993, that law was amended to include the full scope of practice of CNMs under state law, adding newborn care, family planning, gynecological services and primary health care for women. Furthermore, regulations of the Center for Medicare and Medicaid Services (“CMS,” a division of the federal Department of Health and Human Services, or “DHHS”) prohibit state Medicaid plans from requiring CNMs to be supervised by a physician and require the states to pay CNMs directly, regardless of affiliation with a physician. Many states pay CNMs the same as physicians (although Medicare still pays only 65% of the physician rate only).

CPMs and other direct-entry midwives do not have mandated provider status under federal law. State Medicaid plans may add non-mandated services, however, and midwives have convinced some state legislatures or Medicaid offices to include them as providers. As we know from the licensure struggle, it is a long slow process to achieve anything on a state-by-state basis. Presently, only Alaska, Arizona, California, Florida, New Hampshire, New Mexico, Oregon, South Carolina, Vermont, and Washington State include midwives other than CNMs within Medicaid. And the APHA presentation revealed that midwives other than CNMs are actually participating as Medicaid providers only in Florida, New Hampshire, New Mexico, Oregon, South Carolina, Vermont, and Washington.

The main reason why CNMs have achieved nation-wide provider status and CPMs have not is relatively simple. NACPM and MANA do not have a national lobbying presence on Capitol Hill; in fact, neither group has its headquarters in Washington, D.C., where most professional societies and managed care organizations have either their main office or a significant presence. This is not a criticism of NACPM or MANA. CPMs and other midwives have understandably focused their priorities and limited resources where they are most needed – on state legislatures to achieve legal status. A first-things-first approach is a completely reasonable way to deploy limited resources, and reimbursement must take a back seat to licensure.

Now, however, when almost half of the states recognize and license direct-entry midwives, and with several states in process to license CPMs, NACPM has decided it is time to take this issue on. In fact, with the debate about national health insurance heating up as the 2008 presidential election nears, CPMs cannot afford to ignore federal healthcare initiatives. To do so runs the risk that CPMs will be shut out of whatever national health insurance system is developed and, ultimately, adopted. In fact, Congressman John Conyers has introduced a bill, “The United States National Health Insurance Act,” (H.R. 676), which would expand the Medicare system to cover all adults. The bill lists CNMs, but not CPMs, as participating providers. ( See Rep. Conyers’ website at http://www.house.gov/conyers/news_hr676_2.htm).

Thus, it makes sense for NACPM to go to Congress, the source of Medicaid policy and funding, to solve the problem in one step. What must be done, however, to get Congress to recognize CPMs as Medicaid providers? Congress does not consciously favor CNMs over CPMs; rather, the cause for inaction is most likely that CPMs are simply not on the Congressional radar screen. Like state legislators at one time, Congress still doesn’t know you exist or what you do. The time has come, however, for CPMs to bring their excellent outcomes data, their proven lobbying savvy, and their vocal and devoted consumers to Capitol Hill. The support of the highly-respected APHA and the CPM 2000 study by Johnson and Daviss will increase the credibility of CPMs when they turn their attention to Congress.

How can individual CPMs influence this process? While NACPM may retain a professional lobbyist, grassroots support by CPMs and their clients is just as vital at the federal level as in your respective statehouses. Talk to your Congressman, Congresswoman, and your Senator about midwives and out-of-hospital birth. Send them the same birth announcements you send your state representatives. Get to know their staff members. This same education process which has worked so well in the state capitols is also needed here, so that your federal representatives will learn that their constituents want the choice of out-of-hospital birth with CPMs. And plan to attend the NACPM-sponsored pre-conference workshop on October 18th at MANA 2007 in Clearwater, Florida: Midwives and the “Health Care for All” Movement: Let’s Seize the Opportunity to Transform Maternity Care for ALL Women. (Click here for a pdf of the flyer) This workshop will prepare midwives and consumers with the tools and training for federal-level lobbying. Securing federal access to reimbursement for CPMs is an important undertaking for NACPM and I extend my best wishes for your success.