Today on Science & Sensibility, Veronica Jacobsen discusses how perinatal education can be a covered expense under state and private insurance plans. This topic is part of our occasional series "Building Your Birth Business." Having the ability to bill insurers may increase access to childbirth classes for more families and provide opportunities for educators at the same time. Do you bill insurance for the cost of your classes currently? Share your thoughts and comments in our discussion below. - Sharon Muza, Community Manager, Science & Sensibility.

As the market changes and educators start to look at offering childbirth classes in independent settings, the subject of billing insurance for childbirth classes is brought up from time to time. Independent providers in many fields shy away from the idea of billing insurance and opt instead to run cash-only practices where the patient pays the provider directly for services rendered. It's true that cash-based practices are easier to run from an administrative standpoint. However, running cash-only practices have major drawbacks as well. The market for patients who are looking for and/or need to have the costs of perinatal education billed to and paid by insurance is far larger than the market for patients who can or will pay out of pocket. It's often much easier to attract clients if the cost of perinatal education services can be submitted to their health insurance plans. I also worry about the ethics involved in restricting quality perinatal education to only a small pool of parents who are able to afford it out of pocket. While reimbursement rates may end up being lower than cash-only prices, the economics of

When we're talking about the process of Childbirth Educators billing insurance directly for childbirth education, we refer to it as third-party reimbursement. One of the biggest barriers that exist 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 services are covered, who can render those services, and how much are they paid for them.

Part of our existing insurance system is controlled by the federal government. A good example of this is the Affordable Care Act. The Affordable Care Act mandates that breast pumps and breastfeeding support are a covered benefit. Typically the majority of 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 from legislative session to legislative session.

In Minnesota, where I practice, childbirth education is considered a mandatory covered service by the Department of Human Services for residents who have coverage through Medical Assistance programs. Oddly, 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. Families who are on Medical Assistance are either enrolled directly through the state's Medical Assistance or MinnesotaCare coverage. Some of the plans are managed through the state itself, but most are have PMAPs (Minnesota Prepaid Medical Assistance Project plans) that are administered through other health care insurers..

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 and alternative way to deliver childbirth "education". There is a limited body of evidence that shows that perinatal education that focuses on the individual improves outcomes. Our experience tells us that delivering a high quality in-person childbirth education program goes a long way towards families having a safe and healthy birth experience.

To understand what is possible in your state, some research is necessary. This sounds very basic, but it's a matter of plugging terms like your state name and "prenatal education covered services" and going from there to find out what is covered and what you need to do to get reimbursed. You may need to look up "prenatal education" in your state's statutes. Your state may have handbooks that cover maternity care coverage requirements available online. It may be easy to find this information, or you may need to get this information through a couple of different channels. However, don't get discouraged. The answers are out there and available if you look for them!

As for the "how much"...that can get 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 5-10 years. Employer-based plans set their own reimbursement rates, and those rates can vary even within the same insurer as determined by what plan coverage the employer has negotiated. For example, you could have Blue Cross Blue Shield insurance and the contracts state that if the provider bills the insurer for a procedure at $150 and the contractual obligation is to only reimburse $110 of that cost of care; Somebody else with a Blue Cross Blue Shield insurance plan through 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. Even though this may be the case, many childbirth education providers may find that reimbursement amounts average out to be a reasonable rate overall. Especially since we're talking about group education, it's likely that the benefits of getting more families in classes outweigh the downside of having overall slightly lower payment per pregnant person.

Some families are able to pay for the cost of childbirth classes with their Flexible Spending Accounts (FSAs) or their Health Savings Accounts (HSAs) with pretax dollars. The IRS, not the insurers, determines what's an appropriate use for these funds. However, I always advise families to talk to their benefits administrator to verify eligibility and to learn what's needed for documentation and reimbursements. Using FSA/HSA dollars to pay for classes allows for childbirth educators to run cash practices while lessening the economic impact on a family's finances, but it again creates barriers to care for those who don't have this as a benefit.

Childbirth educators can also work to craft legislation on the state and national level that will not only make third-party reimbursement easier, but at a rate that adequately compensates educators for their time and expertise. I'm always looking for other states that may already have legislation in hand that would be easy to replicate; Washington state has existing legislation that could be used for replication in other states.

Hopefully this brief explanation helps you understand the very basics of third-party reimbursement for childbirth education as it exists today. Yes, it's very complicated at first, but once you start to wade into the subject, it is completely possible to begin to understand how you may be able to integrate it into your practice, and how you can work to make childbirth education a reimbursable expense through insurers in your state.

About Veronica Jacobsen

Veronica Jacobsen, BA, CD(DONA), CLC, CPST, LCCE, FACCE is a birth professional supporting families as a certified doula, Lamaze Certified Childbirth Educator, Certified Child Passenger Safety Technician and Certified Lactation Counselor since 2006.

Veronica is an active blogger, writing about maternity care outcomes, evidence-based maternity care, patient rights, advocacy, and infant safety. She is passionate about helping families understand and navigate the very complex US maternity care system, as well as an outspoken advocate for increasing transparency and access to evidence-based maternity care. Veronica has been very successful in obtaining third-party reimbursement through the creation of entities that are innovative and go beyond the private doula and childbirth educator framework. Her goal is to see doula care become more accessible to families, and doula compensation evolve so that more people who want to work as doulas can by allowing them to earn a good wage while being able to balance the needs of their families and other jobs. If you have questions about how third party reimbursement may work for your situation, please contact Veronica through her website.

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