PURPOSE

Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an Administrative Policy. Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation. Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

MIDWIFE SERVICES

Coverage of professional fees for midwife services are subject to the terms, conditions and limitations of the applicable benefit plan and may be limited based on health care professional certification/licensure requirements. In addition, coverage of midwife services may be governed by state mandates; please note licensure and regulations related to midwifery practice and prescriptive authority vary among states.

Network Adequacy Provision (NAP) does not apply to midwife services if a licensed in-network provider (e.g., obstetrician, Certified Midwife, Nurse Practitioner) capable of rendering services is available. For purposes of NAP, midwives and birthing centers are considered ancillary providers. Please see the NAP Utilization Management Policy for further details. Continuity of Care and Transition of Care provisions may apply to midwife services and/or birthing centers. Please refer to the Continuity of Care and Transition of Care Utilization Management policies for further details.

Services provided by a Licensed/Certified Nurse Midwife are eligible for coverage. Services provided by non-nurse midwives (e.g., Certified Midwife [CM], Certified Professional Midwife [CPM], Direct-Entry Midwife, Lay Midwife), may be covered depending on state requirements.

Licensed/Certified Nurse Midwife

Cigna covers services provided by a Licensed/Certified Nurse Midwife acting within the scope of license or certification under the applicable state law.A002 Professional fees for these services are covered at the following benefit levels:

• out-of-network benefit level when services are provided by an out-of-network nurse midwife and when out-of-network benefits exist
• in-network benefit level when services are provided by an in-network nurse midwife

Non-Nurse Midwife

Cigna ONLY covers services provided by a non-nurse midwife (e.g., Certified Midwife [CM], Certified Professional Midwife [CPM], Direct-Entry Midwife, Lay Midwife) when acting within the scope of license or certification under the applicable state law. When eligible for reimbursement as noted above, professional fees for these services are covered at the following benefit levels:

• out-of-network benefit level when services are provided by an out-of-network midwife and when out-of-network benefits exist
• in-network benefit level when services are provided by an in-network midwife

Not Covered

Cigna does not cover ANY of the following:

• Services provided by an out-of-network mid-wife (e.g., Licensed/Certified Nurse Midwife, Certified Midwife) when out-of-network benefits are not available.
• Services at the in-network benefit level, for services provided by an out-of network healthcare provider (i.e., network exception) when a qualified in-network healthcare professional who provides obstetrical services is available, unless required by state regulations or mandates.
• Services provided by a midwife (e.g., Licensed Certified Midwife, Certified Midwife) acting outside the scope of license or certification under the applicable state law.

Doula Services

Doula services (e.g., childbirth education and support services during pregnancy by a trained non-clinician), unless required by state regulations or mandates.

HOME BIRTH SERVICES

Coverage of a planned home birth may be governed by state mandates. A planned home birth is an elective alternative to delivery in a birthing center or hospital setting. Coverage of professional fees for a home birth (i.e., elective, planned delivery in the home setting) is subject to the terms, conditions and limitations of the applicable benefit plan and may be limited based on health care professional certification/licensure requirements.

Cigna covers the professional fee for services provided to a mother eligible for coverage under a Cigna health benefit plan for a home birth, including delivery and immediate medically necessary post-partum care, when services are provided by a health care provider who is acting within the scope of his/her license or certification under the applicable state law.

Cigna covers professional fees for services provided during a home birth at the following benefit levels:

• out-of-network benefit level when services are provided by an out-of-network health care provider and when out-of-network benefits exist
• in-network benefit level when services are provided by an in-network health care provider

Cigna does not cover any of the following services associated with a home birth:

• Services provided by an out-of-network provider when out-of-network benefits are not available.
• Services at the in-network benefit level, for services provided by an out-of network healthcare provider (i.e., network exception) when a qualified in-network healthcare professional who provides obstetrical services is available, unless required by State regulations. : A002
• Services that are not considered eligible for reimbursement (e.g., other than a healthcare provider who is acting within the scope of that provider's license or certification under the applicable state law)
• Duplication of services (e.g., services provided by a licensed physician and licensed certified nurse-midwife simultaneously [i.e., at the same time]).
• Services considered not medically necessary (e.g., non-routine maternity services, additional prenatal counseling sessions, prenatal evaluation and management services specifically related to home birth).
• Items that are excluded or otherwise not covered under the benefit plan (e.g., equipment, supplies [e.g., emergency kits], supplies specifically related to home birth, modifications to the home, standby services [e.g., support personnel]).
• Facility charges for the home setting.

General Background - Midwife Services

Midwifery is a term used to define a complete range of primary health care services provided for women by certified nurse-midwives (CNM) and certified midwives (CM). There are five types of midwives who provide varying levels of care (Graduate Nursing EDU.org, 2018). The different types of midwives are as follows:

• Certified Nurse Midwife (CNM): registered nurse midwife, requires a graduate-level nurse-midwife program and passing of a certification exam from the American Midwifery Certification Board.
• Certified Midwife (CM): a midwife who has completed a graduate-level midwifery degree program and passed a certification exam from the American Midwifery Certification Board. CMs are qualified to provide the same level of care as a CNM.
• Certified Professional Midwife (CPM): has met the certification requirements of the North American Registry of Midwives (NARM); eligibility for the exam is met by either apprenticing with a qualified midwife and completing an Entry-Level Portfolio Evaluation Process or graduating from a midwifery program or school. Practice privileges vary by state.

• Direct-Entry Midwife (DEM): have no national certification or licensing available; legal rights and licensing vary among states. (A CPM, CM, or CNM may be a DEM and some states require some type of certification).
• Lay Midwife (LM): uncertified or unlicensed midwife, no formal education. Licensing among states vary.

Services provided by a midwife generally include provision of primary care, gynecologic and family planning services in addition to care of a newborn for the first 28 days following delivery. Some midwife providers (i.e., CNM, CM) are able to provide care from adolescence to end of life. Midwife services may be provided in a variety of settings such as a home, private office, hospital, birthing center, and ambulatory care clinic or community health center. CNMs can be licensed in all states; in contrast, CMs are not licensed in all states. In addition, regulations related to midwifery practice and prescriptive authority vary among states.

Doula Services

A doula is a maternal support practitioner, non-clinician, trained to provide emotional, informational, and psycho-social support during pregnancy, childbirth, and the postpartum period. Upon completion of training a doula may obtain certification through various agencies, such as Doulas of North America (DONA) or the International Childbirth Education Association. Generally, a doula acts under the supervision of a physician, nurse practitioner, or certified nurse midwife.

Home Birth

Labor and delivery may present hazards to both mother and fetus before and after birth. Planned home birth is associated with a two- to threefold increased risk of neonatal death when compared with planned hospital birth (AAP, 2013). Standards for safe delivery are required and provided when delivery takes place in a hospital or birthing center.

Consistent with the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), Cigna considers a hospital or birthing center the safest setting for labor, delivery, and the immediate postpartum period.

As an alternative, a medically informed decision for a home birth may be chosen by some women. Planned home birth should only be considered for women at low risk of complications and when a qualified health care professional is present. Both AAP and ACOG recommend the use of certified midwives, certified nurse-midwives, or practicing physicians for home births while opposing care provided by lay midwives or other midwives not certified by the American Midwifery Certification Board due to quality and safety concerns (ACOG, 2016). Additionally, the availability of timely transfer and an arrangement with a hospital for potential transfer is necessary for consideration of home birth services.

The American Academy of Pediatrics Policy Statement on Planned Home Birth

The American Academy of Pediatrics policy statement on planned home birth (AAP, 2013) and the American College of Obstetricians and Gynecologists Committee Opinion (ACOG, 2016) recommends the following criteria for an elective home delivery:

Candidate for Home Delivery

• Absence of preexisting maternal disease
• Absence of significant disease occurring during the pregnancy
• Singleton fetus estimated to be appropriate for gestational age
• Cephalic presentation (i.e., baby’s head facing down)
• Gestation between 36-37 to < 41-42 completed weeks of pregnancy
• Labor that is spontaneous or induced as an outpatient
• Has not been transferred from another referring hospital

Systems needed to support planned home birth

• Availability of a certified nurse-midwife, certified midwife, or physician practicing within an integrated and regulated health system
• Attendance by at least 1 appropriately trained individual whose primary responsibility is the care of the newborn infant
• Ready access to consultation
• Assurance of safe and timely transport to a nearby hospital with a preexisting arrangement for such transfers

Newborn care provided in the home setting immediately after delivery should adhere to current standards of practice. Each delivery should be attended by 2 individuals, at least 1 of whom has the appropriate training, skills, and equipment to perform a full resuscitation of the infant in accordance of the principles of the Neonatal Resuscitation Program (AAP, 2013).

Definitions

• Low risk: a term used by clinicians to describe women whose history and condition suggests that there is little likelihood of complications during pregnancy, labor and/or birth.
• Licensed certified nurse-midwife: a licensed certified nurse-midwife is a registered nurse with advanced training who is registered and licensed to practice midwifery. Nurse-midwives provide care and advice to women during pregnancy, labor, birth, the early postpartum period, and care for the newborn baby in a variety of settings, under direct supervision of a licensed physician or independently if authorized by State law.
• In-network benefit level: Coverage level applied when care is provided to a Cigna customer by a doctor, certified nurse-midwife, hospital, clinic, or laboratory that is contracted with Cigna to provide health care services.
• Out-of-network benefit level: Coverage level applied when care is provided to a Cigna customer by a doctor, certified nurse-midwife, hospital, clinic, or laboratory that is not contracted with Cigna to provide health care services, who does not participate in the network associated with the customer's Cigna plan, and only when a customer's health benefit plan allows out-of-network services.