CurrentIndependent HealthPolicy M010412090

Home Births by Licensed Midwives

Defines coverage, authorization, and credentialing requirements for home births performed by physicians or licensed midwives for Independent Health members across specified lines of business in New York State.

Policy Summary

PayerIndependent Health

PolicyHome Births by Licensed Midwives

Policy CodePolicy M010412090

Change TypeNo material changes

Effective DateApr 12, 2001

Next Review DateN/A

Key ActionSubmit staged pre-authorizations: initial prenatal authorization up to 32 weeks, update at 8 weeks before due date for home birth/postpartum/newborn care, and weekly updates after 40 weeks until delivery or 42 weeks, including provider credentials and malpractice evidence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36-42 wksGestational window

$1M/$3MMalpractice limits

RequiredAuthorization

Covered w/ criteriaCoverage stance

NYApplies to

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Coverage Criteria for Home Births

Covered with criteria

Covered when ALL of the following are met

Provider criteria: The midwife has a current New York State midwife license; documentation of a collaborative relationship with a participating OB/GYN physician, a participating physician with obstetric privileges at a participating hospital, or a participating hospital that provides obstetrics; evidence of malpractice insurance with limits of $1,000,000 per occurrence and $3,000,000 aggregate that specifically covers home births; evaluation of the member's health risk; and documentation of the proximity of the backup physician or hospital.

All provider items must be documented

Member criteria: Absence of maternal or fetal disease prior to or during the pregnancy; absence of placental abnormalities; no history of prior complicated deliveries; no history of cesarean delivery; singleton pregnancy; cephalic presentation; and evidence that the midwife carries the necessary equipment and supplies to initiate emergency treatment and has arranged backup and transportation to a nearby hospital if needed.

All member items must be met for authorization

Gestational limits and authorization staging: Requests must meet gestational age limits: minimum 36 completed weeks and fewer than 42 completed weeks. Authorization must be submitted in stages: initial prenatal authorization up to 32 weeks, updated information at 8 weeks prior to the expected due date to authorize home birth/postpartum/newborn care, and weekly updates after 40 weeks until delivery or 42 weeks.36-41+6 weeks; prenatal auth <=32 weeks

Staged prior authorization required

Some employer-sponsored plans that are self-funded may place additional limits on or exclude coverage for planned home births. For members covered under a self-funded Summary Plan Description (SPD), the terms of the employer SPD take precedence over this Independent Health policy.

Planned home birth is not appropriate when maternal or fetal conditions increase risk. Authorization will not meet criteria for members with identified maternal or fetal disease, placental abnormalities, multiple gestation, non-cephalic presentation, a history of prior complicated deliveries, or a prior cesarean delivery. This aligns with clinical guidance noting that hospital or accredited birth center care is preferred for conditions that increase risk to the mother or baby.

Authorization Windows, Gestational Age & Insurance Requirements

Gestational age for home birth authorization — staging and timing

Authorization gestational windowMinimum 36 completed weeks and fewer than 42 completed weeks (i.e., 36–41+6 weeks)

Initial prenatal authorization timingSubmit initial authorization for prenatal services up to 32 weeks of gestation

Second-stage authorization timingSubmit updated authorization at 8 weeks prior to estimated due date to cover home birth, postpartum and newborn care

Late-pregnancy updatesAfter 40 weeks, submit updated authorization information weekly until delivery or 42 completed weeks

Malpractice insurance requirements

Required malpractice limitsMinimum limits of $1,000,000 per occurrence and $3,000,000 aggregate

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Pre-authorization is required. Submit staged authorizations as follows: initial authorization for prenatal services up to 32 weeks gestation; updated medical information submitted eight (8) weeks prior to the estimated due date to obtain the second-stage authorization for home birth, postpartum and newborn care; after 40 weeks gestation, submit updated medical information weekly until delivery or completion of 42 weeks gestation.

Initial authorization: prenatal services up to 32 weeks gestation
Second-stage authorization: submit updated medical information 8 weeks prior to estimated due date
Post-40 weeks: submit updated medical information weekly until delivery or 42 weeks gestation

Denial Risk

Required Documentation and Denial Risk

Authorization requests must include all required provider and member documentation. Requests submitted without the required documentation or that do not meet the listed clinical/member criteria will be denied or returned to the provider.

Definitions

Home birth — definition

DefinitionAn attended or unattended childbirth in a non-clinical setting (residence), typically using natural childbirth methods

Typical attendantsUsually attended by a midwife or lay attendant with expertise in managing home births

Setting distinctionTakes place in a residence rather than in a hospital or a birth center

High risk pregnancy — definition

DefinitionA pregnancy in which the mother, fetus or newborn is or will be at an increased risk for morbidity or mortality before or after delivery

Implication for coveragePregnancies meeting high-risk criteria are not appropriate for planned home birth authorization

Background and Clinical Guidance

Professional organizations cited in Independent Health's evaluation conclude that hospitals and accredited birth centers are the safest settings for birth. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) state they do not recommend planned home birth, and NICE guidance identifies clinical conditions that increase maternal or fetal risk where hospital-based care is preferred.