AABCâis hard at work to mandate the facility fee in Medicaid. The only permanent solution for birth centers in the Medicaid program and with other insurers is to pass legislation making birth centers an official mandated facility.
CMS--What is it? CMS stands for the Centers for Medicare and Medicaid Services. Medicaid is BOTH a federal AND state program. CMS is the federal part. CMS makes and interprets the rules for what state Medicaid agencies can and cannot do. It has the power to approve or veto all Medicaid payments made to your states. CMS has the power to approve or disapprove your state Medicaid plan, and pays for about half of the dollars each state pays out for Medicaid services. Your state dollars make up the other half of what is paid to you. CMS has told the state Medicaid plans that birth centers are not eligible for Medicaid payment and has disapproved payment of the federal half if states continue to pay for birth center facility fees.
How do they select who gets paid and who is denied? CMS interprets the Medicaid Act and decides if state plans are compliant with the Act. The federal Medicaid law lists the types of providers and services that are eligible for payment. Hospitals, clinics, nurse-midwives are listed, but birth centers are not. Until recently, some states paid birth center charges above and beyond the midwife's professional fee, but did so based upon an interpretation of the Medicaid law. CMS top officials, at the present time, have a new interpretation, which leaves out birth centers, and no longer accept the former interpretation. This means that if the birth center is to get paid for the facility, the birth center must to be added to the Act as a distinct category of provider, like hospitals or clinics. And, the ONLY WAY this can be done is by passing a bill through Congress to amend the Medicaid law.
For example, payment for nurse-midwives outside the maternity cycle wasn't eligible for Medicaid payment until it was added by Congressional amendment in 1993. After that amendment, payment for ALL professional services provided by Certified Nurse-Midwives (CNMs) became mandated to be covered in all states. Another example is the American College of Nurse-Midwives' (ACNM's) bill to amend the MEDICARE law to increase payment levels for CNMs higher than 65% of physician fee levels (Medicare is the program for the elderly and disabled, while Medicaid is the program for the poor and uninsured). Since CMS is taking the position that the birth center, as a facility, is not a Medicaid-eligible provider . Some states might still be paying the facility fee at present, but this payment is threatened. Texas has been denied payment for birth centers--after paying them for over 20 years. So, if you are presently getting Medicaid payment in your state for more than the nurse-midwife's fee, it's only a matter of time until CMS catches up to your state and puts a stop to it.
Who decides how birth centers are paid, the federal government in Washington or my state? States make decisions about how much you are paid for Medicaid births. The federal government, however, runs the program and controls how federal Medicaid dollars are spent by the states. Since the federal government contributes about half of the state's payment to you and other providers, it controls the ultimate eligibility rules that determine which providers may be paid by each state. It does so by enforcing and interpreting the Medicaid law, which only Congress (the Senate and the House of Representatives in Washington, D.C.) can amend. CMS has ruled that, since birth centers are not listed in the Medicaid law, that means that birth center facility fees are not eligible for Medicaid payment as a covered service. If your center has CNMs, they will continue to be paid professional fees on the basis that the federal law requires payment of nurse-midwife PROFESSIONAL FEES. If we can pass a bill adding the birth center facility to the Medicaid Act, all birth centers will have to be paid a facility fee for Medicaid births. Right now only about 20 states are being paid for facility charges. In many of those states, however, the center must have a Medical Director and is paid as a "clinic." We don't want birth centers to be stuck with a federal requirement that they must have a medical director.
If I am being paid right now, why is this a problem for me? First, because it's only a matter of time until CMS catches up with your state. If you don't have a medical director and if the state doesn't classify you as a clinic, you will lose the facility charges component of your payment. Second, private insurers follow what CMS determines as policy. They may at any time learn about and agree with CMS and then begin to deny facility payment to birth centers. We must act quickly and to get our bill introduced and passed before this problem gets worse!
How does this affect birth centers owned or staffed by Certified Professional Midwives (CPMs) or other direct-entry midwives? This is a good question. About 9 or 10 state Medicaid plans pay direct entry midwives, even though the federal Medicaid law does not list CPMs or other direct entry midwives, it DOES permit states to pay any health professional licensed in the state. So, states that license direct-entry midwives may also choose to pay them under the state Medicaid plan and CMS will not dispute it. The problem is that this federal provision only applies to state-licensed PROFESSIONALS, not state-licensed FACILITIES. Since birth centers are facilities, not professionals, they don't qualify for this exception, although CPMs and other direct-entry midwives certainly do. AABC looks forward to the day when all midwives in all states will be eligible for Medicaid payment.
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