CurrentmhnPolicy CP.MP.136

Home Birth (PDF)

Defines medical necessity criteria under which planned home births are considered covered by Centene-affiliated health plans, including provider credentialing, emergency transport planning, staffing, and maternal/fetal risk restrictions.

Policy Summary

Payermhn

PolicyHome Birth (PDF)

Policy CodePolicy CP.MP.136

Change TypeRevised (annual reviewcriteria reorganized)

Effective Date

Next Review Date

Key ActionDocument provider credentialing, emergency transport plan with ≤15 minute transport, planned staffing including NRP-certified provider, and confirm low-risk pregnancy criteria per policy.

SourceLink

POLICY UPDATE CHANGES

Removed previous criteria I.C. through I.I. and created new criteria I.C.1. through I.C.8.

Edited language regarding emergency facility access for physician-overseen care to match midwife-overseen care and clarified Neonatal Resuscitation Program certification requirement.

Added option for family practice physicians who have completed an OB fellowship to attend a home birth without a supervising OB.

8Specific low-risk pregnancy criteria required

2Required onsite providers at delivery

15Maximum emergency transport time (minutes)

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Referenced CPT delivery codes (informational)

Coverage Summary

Overview: Planned home birth is described as an elective alternative to delivery in a birthing center or hospital setting. This policy defines the specific conditions under which planned home births are considered medically necessary and covered by Centene-affiliated health plans, including provider credentialing, emergency transport planning, required onsite staffing, and maternal/fetal risk restrictions.

Coverage stance and metadata: Coverage stance: covered_with_criteria. Policy number: CP.MP.136. Subject: Planned Home Birth coverage criteria. Status: CURRENT. The policy was last reviewed 01/26 and includes an annual review history noting updates to criteria with no impact to coverage determinations.

At-a-glance criteria

Emergency transport time<= 15 minutes from onset of an emergency condition

Gestational age window>= 37 0/7 and <= 40 6/7 weeks

Required onsite providers at delivery2 (one responsible for birthing individual; one responsible for infant)

Neonatal resuscitation requirementAt least one provider certified in the Neonatal Resuscitation Program with full resuscitation equipment

Number of low-risk pregnancy criteria8 specified criteria (singleton, anatomy ultrasound normal, cephalic, gestational age 37 0/7–40 6/7, no prior cesarean, no prior uterine surgery, no preexisting high-risk conditions, no complications)

Referenced informational CPT delivery codes4 (59400, 59409, 59410, 59414)

Medically Necessary Criteria for Home Birth

Provider Actions / Documentation Requirements

Documentation Required

Provider credentialing and certification documentation

Document participating and credentialed status. For midwives, include certification by the American Midwifery Certification Board (or predecessor) OR documentation that the midwife's education and licensure meet International Confederation of Midwives Global Standards for Midwifery Education, and that they are practicing within an integrated and regulated health system. For physicians, document that they practice obstetrics within an integrated and regulated health system and, if not an obstetrician or family physician with an OB fellowship, provide documented proof of back-up supervision and coverage by a board certified or active candidate for certification by the American Board of Obstetrics and Gynecology.

Midwife: AMCB certification OR education/licensure meeting ICM global standards and practice within an integrated and regulated health system
Physician: practices obstetrics within an integrated and regulated health system
Physician without OB training: documented back-up supervision/coverage by a board-certified or active candidate for ABOG certification

Documentation Required

Emergency transport plan documentation

Coding

Informational CPT Codes referencedCPT

59400	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
59409	Vaginal delivery only (with or without episiotomy and/or forceps)
59410	Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
59414	Delivery of placenta (separate procedure)

Background and Evidence

Background on professional society positions and evidence: ACOG and AAP do not recommend planned home birth as the safest setting and note increased neonatal risks; however, both organizations recognize the birthing individual's right to make a medically informed decision. ACOG reports that planned home birth is associated with more than a twofold increased risk of perinatal death and about a threefold increased risk of neonatal seizures/serious neurologic dysfunction in some analyses, while the AAP reports a two- to threefold increase in infant mortality in the United States.

Nature of evidence and emphasis on screening and transfer systems: Most evidence about planned home birth is observational with mixed findings across countries and study designs, and observational studies have methodological limitations. Because of safety concerns, the policy and professional guidance emphasize appropriate candidate risk screening and that planned home birth include systems for collaboration, referral, and timely transfer to hospital care when problems arise; travel times longer than 15 to 20 minutes have been associated with increased risk, and the policy requires documentation that emergency transport to the nearest appropriate hospital can be accomplished within <= 15 minutes from onset of an emergency condition.

Evidence summaries

Definitions

Revision History

01/26annual review / revisedLatest

Annual review. Removed previous criteria I.C. through I.I. and created new criteria I.C.1. through I.C.8. Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist. (is_material=true)

01/22annual review / revised

Annual review. Edited language regarding emergency facility access for physician-overseen care to match midwife-overseen care; reformatted I.B and clarified that at least one provider is certified in the Neonatal Resuscitation Program. References reviewed and updated.

09/21

Policy Summary

Payermhn

PolicyHome Birth (PDF)

Policy CodePolicy CP.MP.136

Change TypeRevised (annual reviewcriteria reorganized)

Effective Date

Next Review Date

Key ActionDocument provider credentialing, emergency transport plan with ≤15 minute transport, planned staffing including NRP-certified provider, and confirm low-risk pregnancy criteria per policy.

SourceLink

On This Page

Include a written emergency care plan that documents that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from the onset of an emergency condition.

Written plan for emergency care must document transport time <= 15 minutes to nearest appropriate hospital

Documentation Required

Staffing and neonatal resuscitation documentation

Document that two care providers will be present at the birth, with roles delineated: one provider with primary responsibility for the birthing individual and one provider with primary responsibility for the infant. Document that the infant-responsible provider is certified in the Neonatal Resuscitation Program (NRP) and that appropriate equipment is available to perform a full neonatal resuscitation per NRP principles.

Planned presence of two care providers
One provider designated primary for the birthing individual
One provider designated primary for the infant and certified in the Neonatal Resuscitation Program
Documentation of equipment to perform full neonatal resuscitation in accordance with NRP

Documentation Required

Low-risk pregnancy documentation

Document that the pregnancy is low-risk by confirming all required elements below.

Singleton pregnancy with appropriate dating confirmed by ultrasound
Anatomy ultrasound performed with no evidence of abnormalities
Fetal presentation is cephalic (vertex)
Gestational age at planned home birth >= 37 0/7 and <= 40 6/7 weeks (spontaneous labor)
No prior history of cesarean delivery
No prior uterine surgery (e.g., myomectomy entering the myometrium)
No preexisting medical conditions that increase pregnancy risk
No complications during pregnancy

annual review / clarified

Annual review. Added option for family practice physicians who have completed an OB fellowship to attend a home birth without a supervising OB; removed WHO background information and updated references.