19-247 Member Access to Freestanding Birth Centers and Midwife Services
Date: 04/30/19
Medi-Cal patients can access different birthing options based on what works best for them and their families
California Health & Wellness Plan (CHWP) and other Medi-Cal managed care health plans (MCPs) must allow members access to:
- Freestanding birth centers (FBCs)1
- Services from certified nurse midwives (CNMs)
- Licensed midwives (LMs)
Network requirements are outlined below.
MAINTAIN AN ADEQUATE NETWORK
The MCP network must include, at a minimum:
- one FBC,1
- one CNM; and
- one LM
Documentation of these provider types in its network must be maintained.
PROVIDE ACCESS TO OUT-OF-NETWORK PROVIDERS
If no participating FBC, CNM or LM is available, members can access out-of-network services. If network deficiencies exist for these provider types, services to out-of-network providers must be authorized.
REIMBURSE OUT-OF-NETWORK PROVIDERS ADEQUATELY
Out-of-network FBCs, CNMs and LMs must be reimbursed no less than the applicable Medi-Cal fee-for-service (FFS) rates for services.
SELECT CONDITIONS ALLOW FOR NOT CONTRACTING WITH AN FBC, CNM OR LM
MCPs are not required to contract with an FBC, CNM or LM if:
1 The provider is unwilling to accept the higher of the contract rates or the
Medi-Cal FFS rates.
2 The provider does not meet applicable professional standards. Or, the provider has disqualifying quality of care issues (documented concerns with the provider’s quality of care must be available).
WHAT YOU NEED TO KNOW ABOUT FBCs, CNMs AND LMs
FBCs
Federal law defines an FBC as a health facility:
- That is not a hospital.
- Where childbirth is planned to occur away from the pregnant woman’s residence.
- That is licensed or otherwise approved by the state to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the plan.
- That complies with such other requirements relating to the health and safety of individuals furnished services by the facility as the state shall establish.
CNMs and LMs
The Department of Health Care Services (DHCS) authorizes CNMs and LMs as providers of all services permitted within the scope of the practitioner’s license.2 Both are authorized under state law to provide prenatal, intrapartum, and postpartum care. This includes family planning care for the mother and immediate care for the newborn. The table below outlines the differences between the two provider types and conditions under which they can provide care.
Midwife type | Licensing | Services |
CNM | Licensed as a registered nurse and certified as a nurse midwife by the California Board of Registered Nursing. | Permitted to “attend cases of normal childbirth” |
LM | Licensed as a midwife by the Medical Board of California. | Permitted to “attend cases of normal pregnancy and childbirth, as defined” and must adhere to a detailed set of restrictions and requirements when a patient’s condition deviates from the legal definition of normal. |
ADDITIONAL INFORMATION
For more information on network access for FBCs, CNMs and LMs, refer to DHCS All Plan Letter (APL) 18-022.
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website at www.CAHealthWellness.com.
Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.
1 California State Plan Amendment (SPA) 11-022 added FBCs – also referred to in the SPA as Alternative Birth Centers (ABCs) – to the State Plan, as federally mandated.
2Refer to the California State Plan, Section 3 – Services at www.dhcs.ca.gov/formsandpubs/laws/Pages/Section3.aspx. See Limitations on Attachment 3.1-A.