Health First Home Births Form

A Florida Planned Home Birth

may be covered as an alternative to a facility-based delivery as described in Florida Administrative Code Chapter 64B24-7 Midwifery Practice. Post-delivery care of the mother and newborn, including a post-partum assessment, newborn assessment, and medically necessary tests and immunizations may also be covered when provided in the home by a qualified practitioner as mandated per Florida state statute Title XXXVII Chapter 627 Section 6406.

Description:

Although hospitals and birthing centers are considered the safest birth settings, the right of a woman to make a medically informed decision about delivery location is respected. Coverage for home births for low-risk pregnancies that are expected to result in a normal delivery may be covered. If an expectant mother is deemed to be an appropriate candidate for home birth as described in Florida Administrative Code Chapter 64B24-7 Midwifery Practice, a home delivery performed by a qualified physician or a licensed midwife meeting requirement defined in Chapter 467 of the Florida State Statutes may be covered, subject to the same cost-share amounts as a hospital delivery.

Clinical Criteria: (Indications/Limitations)

1. Prior authorization is required for a Planned Home Birth.
2. Pursuant to Florida Administrative Code Chapter 64B24-7 Midwifery Practice, the licensed midwife will perform a Risk Assessment by gestational age of 20 weeks, which must be submitted to the Health Plan for consideration (see form below).

• In addition to the Risk Assessment, authorization requests must include ALL the following:
  • A written Emergency Care Plan: A written plan of action to ensure continuity of medical care throughout labor and delivery and to provide for immediate care if an emergency arises. The family should have specific plans for medical care before, during and after the delivery.
• An Informed Consent signed by the member (Attachment #1 - Form DH-MQA 1047, revised 3/01; Informed Consent for Licensed Midwifery Services)
  Florida Regulation: 64B24-7.005 Informed Consent
  (1) A licensed midwife shall obtain a patient's consent for the provision of midwifery services. Such consent shall be recorded on the Informed Consent for Licensed Midwifery Services, Form DH- MQA 1047, revised 3/01, which is hereby adopted and incorporated by reference, and can be obtained from the Council of Licensed Midwifery, 4052 Bald Cypress Way, BIN #C06, Tallahassee, Florida 32399-3256.
  (2) To complete the consent form, the licensed midwife shall inform the patient of:
  • The licensee's qualifications to perform the services rendered.
  • The nature and risks of the procedures to be used.
  • The advantages of the procedures to be used.
  • Professional liability insurance status.
  (3) A signed copy of the consent form shall be placed in the patient's record.

III. Planned home births require prior authorization and may be Covered when the delivery is overseen by a Physician, Certified Nurse Midwife, or licensed Midwife and authorized in advance by the Health Plan.

1. Prior Authorization will be considered for low-risk pregnancies that are expected to result in a normal labor and delivery, after examination and evaluation by a licensed Midwife or Obstetrician.
2. An informed consent, signed by the mother, a written plan of action that provides for immediate medical care if an emergency arises, and risk evaluation form must be submitted for Authorization consideration.

Limitations:

1. Items and services that are not considered medically necessary are not covered (i.e. water birth supplies).
2. Additional exclusions as outlined in Chapter 64B-7 Midwifery Practice (see below).
3. High Risk Pregnancies, as identified by a cumulative risk assessment score of three points or higher, will not be authorized for home birth without a physician authorization that the pregnancy is expected to be a normal birth.

STATE OF FLORIDA - CHAPTER 64B24-7 MIDWIFERY PRACTICE Rulemaking Authority 456.004(5), 467.005 FS. Law Implemented 467.015 FS. History– New 7-14-94, Formerly 61E8-7.004, 59DD-7.004, Amended 9-11-02, 2-2-06, 4-1-09

64B24-7.004 Risk Assessment.

(1) For each patient, the licensed midwife shall assess risk status criteria for acceptance and continuation of care. The general health status and risk assessment shall be determined by the licensed midwife by obtaining a detailed medical history, performing a physical examination, and taking into account family circumstances along with social and psychological factors. The licensed midwife shall risk screen potential patients using the criteria in this section. If the risk factor score reaches 3 points the midwife shall consult with a physician who has obstetrical hospital privileges and if there is a joint determination that the patient can be expected to have a normal pregnancy, labor and delivery the midwife may provide services to the patient. When a client has a risk score of 3 or higher and has previously had a physician consultation for the identical risk factors in a prior pregnancy with no current changes in health or risk factors another consultation is not required.

(2) The licensed midwife shall continue to evaluate a patient during the antepartum, intrapartum and postpartum. If the cumulative risk score reaches three points or higher and the patient is not expected to have a normal pregnancy, labor and delivery, the midwife shall transfer such patient out of his or her care. The midwife may provide collaborative care to the patient pursuant to Rule 64B24-7.010, F.A.C.

64B24-7.004 Risk Assessment (continued)

• Residence of anticipated birth more than 30 minutes from emergency care.

Documented Problems in Maternal Medical History:

1. Cardiovascular System:
   • a. Chronic hypertension.
   • b. Heart disease.
   • c. Heart disease assessed by a cardiologist which places the mother or fetus at no risk.
   • d. Pulmonary embolus.
   • e. Congenital heart defects:
     • i. Congenital heart defects assessed by a cardiologist which places the mother or fetus at no risk.
2. Urinary System:
   • a. Renal disease.
   • b. History of pyelonephritis.
3. Psycho-Neurological:
   • a. History of psychotic episode adjudged by psychiatric evaluation and which required use of drugs related to its management, but not currently on medication.
   • b. Current mental health problems requiring drug therapy.
   • c. Epilepsy or seizures in the last two years.
   • d. Required use of anticonvulsant drugs.
   • e. During the current pregnancy, drug or alcohol addiction, use of addicting drugs.
   • f. Severe undiagnosed headache.

Other Systems:

4. Endocrine System:
   • a. Diabetes mellitus.
   • b. History of gestational diabetes.
   • c. Current thyroid disease:
     • i. Euthyroid.
     • ii. Non-Euthyroid
5. Respiratory System:
   • a. Chronic bronchitis:
     • i. Current or chronic or with medication.
     • ii. Without medication or current problems.
   • b. Smoking:
     • i. 10 or less cigarettes per day.
     • ii. More than 10 cigarettes per day.
6. Other Systems:
   • a. Bleeding disorder or hemolytic disease.
   • b. Cancer of the breast in the past five years.

Documented Problems in Obstetrical History:

• a. Expected Date of Delivery (EDD) less than 12 months from date of previous delivery.
• b. Previous Rh sensitization.
• c. 5 or more term pregnancies.
• d. Previous abortions:
  • i. 3 or more consecutive spontaneous abortions.
  • ii. Two consecutive spontaneous abortions or more than three spontaneous abortions.
  • iii. 1 septic abortion.
• e. Uterus:
  • i. Incompetent cervix, with related medical treatment.
  • ii. Prior uterine surgery.
  • iii. Prior uterine surgery followed by an uncomplicated vaginal birth.
• f. Previous placenta abruptio.
• g. Previous placenta previa.

h. Severe pregnancy induced hypertension during last pregnancy.

i. Postpartum hemorrhage apparently unrelated to management.

Physical Findings of Previous Births:

8. Stillbirth occurring at more than 20 weeks gestation or neonatal loss (other than cord accident).
9. Birthweight:
   • i. Less than 2500 grams without a subsequent for gestational age low risk pregnancy and full term appropriate (AGA) infant.
   • ii. Less than 2500 grams or two or more previous premature labors after a low risk full term AGA infant(s) subsequently delivered, pregnancy.
   • iii. More than 4000 grams.
10. Major congenital malformations, genetic, or metabolic disorder.

Maternal Physical Findings:

9. Gestation:
   • i. Of more than 22 weeks in the patient's first pregnancy (nullipara), unless the patient provides a copy of a medical record documenting a prenatal physical examination and prenatal care by a licensed physician, advanced registered nurse practitioner, or licensed midwife trained in obstetrics and gynecology who regularly provides maternity care.
   • ii. Of more than 28 weeks if the patient has had at least one previous viable birth (multipara), unless the patient provides a copy of a medical record documenting care by a licensed physician, advanced registered nurse practitioner, or licensed midwife provides maternity care.
10. Weight is not within the range of the following weights: b.
    • i. For mothers with a pre-pregnancy body mass index (BMI) below 19.8 or above 26,
    • ii. For mothers who gain more or less weight than recommended by their healthcare provider based on their individual needs.

Prepregnant weight by height:

Height in Inches Without Shoes Prepregnant Minimum Weight in Pounds Prepregnant Maximum Weight Pounds
56 83 143
57 85 146
58 86 150
59 89 153
60 92 157
61 95 161
62 97 166
63 100 170
64 103 175
65 106 180

Current Laboratory Findings

1. Hematocrit/Hemoglobin:
   • (i) Less than 31% or 10.3 gm/100 ml - 1 point
   • (ii) Less than 28% or 9.3 gm/100 ml - 3 points
2. Sickle cell anemia - 3 points
3. Pap smear suggestive of dysplasia - 3 points
4. Evidence of active tuberculosis - 3 points
5. Positive serologic test for syphilis confirmed active - 3 points