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Katrina: 

Please change this policy to allow coverage and reimbursement for midwives. I know many families that desire a homebirth but are restricted because of insurance. This would open many doors for expectant families and midwives alike! Our state needs to be proactive in providing the best care for all individuals, and that includes for pregnancy and childbirth too!

OHCA Response: 

Thank you for your comment. The purpose of the proposed policy changes, APA WF #25-08 and OK SPA #25-0001, is to comply with and implement SB1739 of the 2024 legislative session. SB1739 directs the Oklahoma Health Care Authority to seek federal approval for coverage and reimbursement for CABC-accredited birthing centers. The proposed policy changes allow coverage and reimbursement of licensed midwives’ services provided in birthing centers, in accordance with SB1739. 

Meredith:

I absolutely support this policy change. I have had all my babies with a midwife, and it is absolutely incredible. However, it was a sacrifice, as none of my births were covered in any way by any insurance. This policy change would allow more people to have the experience they desire, but can’t afford.

OHCA Response:

Thank you for your comment. 

Amaya:

Access to midwifery care has been considered a luxury due to out of pocket cost and the lack of coverage by insurance. Midwifery care saves lives and should be accessible by ALL people. This would be a great step towards promoting the health of birthing people in OK. All for it! However, midwives deserve to be reimbursed 100% of the physician fee for services they provide. This is a good start.

OHCA Response:

Thank you for your comment. 

Omare:

I am writing to share, I hope policymakers and others recognize that the Commission for the Accreditation of Birth Centers (cABC) accreditation standards ensure birth centers have established systems for consultation, collaboration and referrals without added written agreements. Maintaining this flexibility, centers can continue to provide high-quality care according to the unique needs of mothers and their baby, and continue to adhere to rigorous standards set. 

OHCA Response:

Thank you for your comment. 

Justin:

I do not support this policy change.

Midwives are important to providing obstetric care, but not without adequate back up from an obstetrician in a licensed hospital facility where optimal patient care can take place.

 If birthing centers are are going to be conducting intrapartum and postpartum care as is provided in a hospital, the birthing centers should absolutely be licensed like a hospital. Especially if complications that arise in a birthing center are to be transferred to a licensed hospital facility to manage those complications.

This bill will not improve maternal health outcomes or access to QUALITY care.

Delivery should occur in a hospital Or a setting of equal caliber to ensure patient safety. Horrible outcomes occur when obstetric emergencies arise in a patient has to be transferred to a licensed facility. Lives will be endangered - Both mother and baby.

I urge lawmakers to oppose passage of this policy. Think of your mother’s, your wives, your sisters and your daughters. What would you want for them? If your answer is access to the best care available, it would be in a hospital setting not a birthing center. 

OHCA Response:

Thank you for your comment. These proposed policy changes remove the state licensure requirement for birthing centers as directed by the Oklahoma legislature. Senate Bill 1739 of the 2024 regular legislative session ended state licensing of birthing centers (63 OS 1-702a). It also directed the OHCA to cover services provided in a birthing center that is not licensed but is accredited by the Commission for the Accreditation of Birth Centers (63 OS 5029.1). Birthing center services are a mandatory Medicaid benefit under the Social Security Act (42 USC 1396d).

Anonymous:

This is TERRIFYING and a disgrace. Why shouldn’t birth centers need to be state licensed anymore? Complications in pregnancy and childbirth are unfortunately common and oftentimes unpredictable. It’s a shame we are putting our very own Oklahoma women at risk by allowing birth centers to forgo state licensing. The sad part is- most patients won’t know the difference until something bad happens. Sometimes, the life of the mother or baby has a matter of MERE MINUTES to be saved. Traveling from a birth center to a tertiary care hospital takes double or triple that. Licensing is needed so they can be better equipped to handle complications.

Further, if midwives are going to be reimbursed 80% of what a physician is, they should be expected to be 80% qualified. They need to learn how to perform their own 3rd and 4th degree lacerations. They need to manage the long term complications like fecal incontinence and revisions of poorly repaired or non-healing lacerations. They need to learn how to expedite delivery with a vacuum or forceps if the baby is decompensating during delivery. They should learn how to do CPR and fully resuscitate a critical baby if they didn’t get it out fast enough. They need to learn how to do a cesarean section, not only in an emergent situation, but also preemptively to prevent morbid situations such as severe life threatening shoulder dystocia, head entrapment, or worse. If they’re going to be paid 80%, they also need to take some liability of the outcome after they transfer their patients to the hospital. The outcome is typically dependent on how long they waited to transfer and it’s unfair and gross for the physician to take full liability for something that could have been prevented.

What often happens is birthing centers ignore the fact that there is fetal distress, inadequate room, or worse. Then at the last minute after the baby is deeply wedged into the birth canal, for example, they transfer patients to the hospital and leave it for the hospital team to save the baby. The physician will then take ALL of the liability of birth injury while trying to get the poor baby out and the midwife, who ignored the situation at hand, gets to sit there, watch, and forgo any legal responsibility. OBGYNs are tired of cleaning up their mess and taking responsibility for their mistakes. If this passes, MIDWIVES NEED TO LEARN HOW TO MANAGE THEIR OWN COMPLICATIONS. We’re tired of being taken advantage of. We’re tired of the emotional stress and PTSD of taking care of their mistakes. We are being treated DIRTY and no one seems to care.

OHCA Response:

Thank you for your comment. These proposed policy changes remove the state licensure requirement for birthing centers as directed by the Oklahoma legislature. Senate Bill 1739 of the 2024 regular legislative session ended state licensing of birthing centers (63 OS 1-702a). It also directed the OHCA to cover services provided in a birthing center that is not licensed but is accredited by the Commission for the Accreditation of Birth Centers (63 OS 5029.1). Birthing center services are a mandatory Medicaid benefit under the Social Security Act (42 USC 1396d).

Ayri:

As a public health professional, Professor and certified doula in training, I strongly support this policy update to establish coverage/reimbursement of birthing centers and licensed midwives. The maternal mortality crisis in Oklahoma is remarkable and very preventable. There is research that provides evidence that midwifery care and the support of doulas during birth greatly decreases the risk for c-sections, hemorrhage and other serious postpartum pregnancy complications. The midwifery care model has historically and presently been shown to improve maternal and infant health outcomes among the 85% of birthers who are considered low risk.

I speak/act and advocate in solidarity with all birthers in Oklahoma, particularly those who have been most impacted by maternal mortality--Black and Indigenous mothers. In order to end this epidemic of preventable death, unnecessary c-sections and improve overall birthing experiences, I urge legislators to approve this policy change. Now more than ever, we need to create changes that improve the health, wellbeing and healing of our communities. Maternal mortality has more than doubled since the 1970s, but we have the power to reverse these preventable deaths. While hospitals are a necessary component of maternal/obstetric care, birthers in Oklahoma need options for childbirth beyond the hospital that honor their preferences for birthing and increase their chances of having safe pregnancies, safe labor and anti-abusive delivery. I support any legislation that keeps Oklahoma birthers safe, healthy and whole as they transition into parenthood. 

OHCA Response:

Thank you for your comment. 

Grant:

I have seen many catastrophic outcomes when midwives do not have written preplanned agreements with covering physicians. I would vote strongly against not having a written agreement.

OHCA Response:

Thank you for your comment. 

Regina:

I am grateful for all the work going into this plan, I respectfully request to review part 87 concerning Birthing centers. Abolishing the optional OK license for birth centers in 2024, was proposed to remove barriers for birth centers, to have a more streamlined approach to seeking reimbursement for the care we provide. Additionally, opening up the midwifery model of care to those who desire it that qualify for CMS coverage. Through the Omnibus,  this has also been a federal goal in order to help improve maternal outcomes. 

SB 1739 statute, states CABC accreditation is deemed status for reimbursement from CMS. Part 87 of the state plan calls for “written” agreement with a Board certified OB for coverage of consultation, collaboration, and referral services. Additionally, “written” agreement with a referral hospital which is a class II hospital  is also required.  These are barriers that were removed when the legislature abolished the birth center license. 

As a Birth Center owner, I have had both of these agreements in the past. It was problematic due to politics of the hospital system. For instance, I could get a written transfer policy from the hospital, but not a written agreement with a private OB from that hospital because the hospital system did not own or employ my birth center. Eventually, it led to cancellation of the transfer policy, and we were directed to bring our patients into OB triage if help was needed. This led to us establishing relationships with several of the local hospitals that had in house laborist available 24 hours a day. We have been diligently, working with the hospitals and a program called Smooth Transitions to jointly work on streamlining the transfer protocols to ensure they are “smooth”. 

Additionally, forming written agreements with particular hospitals and particular OBs limits the patient choice of hospital if need for transfer arises. Considering 98% of hospital transfers are non-emergent, when a patient has a particular system they desire, we collaborate with that system when feasible. 

Finally, as CNMs and CPMs, we have a professional responsibility to work collaboratively within the healthcare system. CABC recognizes that evidence of collaboration and appropriate transfer is the goal, and what ultimately leads to better outcomes.  Furthermore, contracts may prevent the formation of birth centers in much needed areas if the hospital is willing to care for the patient but unable to enter into a written contract. 

I am happy to clarify any of these points and hope we are able to move this plan forward in a way that is inclusive of the care needed to help the families of Oklahoma thrive. 

OHCA Response:

Thank you for your comment. The requirements for written agreements with a board-certified OBGYN for consultation, collaboration, and referral and with a Class II hospital exist to protect patient safety and ensure that members are referred to a higher level of care when appropriate. Further, the requirements for written agreements are important to maintain program integrity by ensuring that medically necessary care is delivered in the most appropriate setting. These requirements for written agreements are distinct from the current requirement of state licensure and the proposed requirement of CABC accreditation.

This proposed policy does not prevent members' free choice of provider. Should a member who is receiving services from a birthing center require referral to a higher level of care, OAC 317:30-3-14 ensures they are able to receive services from any provider they choose who is contracted with OHCA and qualified to provide those services. 

Maria:

The Commission for the Accreditation of Birth Centers (CABC) would like to comment on the Oklahoma SPA #25-001 and APA WF #25-08 Birthing Centers and Licensed Midwives proposed policy changes.

CABC supports the proposed revision that Oklahoma Birthing centers must be accredited by CABC for reimbursement; however, reimbursement for midwives should be 100% of the physician reimbursement for the same service.

CABC also strongly recommends that the Oklahoma Health Care Authority delete the requirement for a written transfer agreement with a board-certified OB/GYN AND with referral hospital.

CABC requires accredited birth centers to have a detailed plan for providing smooth access to hospital and obstetric and neonatal care specialists when needed and this is quite possible to achieve without formal agreements.

Requirements for formal collaborative agreements do not ensure physician availability when needed, and there is no evidence that they improve the safety or quality of care.

Written transfer agreements are often impossible to obtain due to hospitals' perceived medicolegal and business competition concerns.

Requirements for formal transfer agreements create insurmountable barriers to opening a birth center, thus preventing access to the birth center model of care, a model that has repeatedly been shown to improve perinatal outcomes.

Regulatory requirements for written transfer agreements create an unfair economic disadvantage for birth centers and midwives.

Federal EMTALA laws require that hospitals accept transfers of people in labor, making written transfer agreements redundant and unnecessary.

Appropriate policies will ensure that childbearing families in your state have access to the safe, high quality, evidence-based maternity care.

OHCA Response:

Thank you for your comment. The current Oklahoma Medicaid State Plan requires that birthing centers maintain written agreements with a board-certified OBGYN for consultation, collaboration, and referral and with a Class II hospital (Attachment 3.1-A, Page 9a-3). These requirements exist to protect patient safety and ensure that members are referred to a higher level of care when appropriate. Further, the requirements for written agreements are important to maintain program integrity by ensuring that medically necessary care is delivered in the most appropriate setting.

Jill:

Thank you for allowing us to comment on the proposed policy changes to birth centers and licensed midwives. I am writing as a representative of the American Association of Birth Centers (AABC). 

Midwifery-led care is the model provided in birth centers, with longer prenatal visits, and enhanced patient-centered care the norm.  Multiple studies, including the national Strong Start study, have demonstrated that not only is birth center care safe for people experiencing a lower-risk birth but that some outcomes are better with birth center care and birth in the birth center than in typical care.

These significantly improved outcomes included lower preterm births, fewer low birthweight births, fewer cesarean, higher breastfeeding rates, and fewer emergency room visits over the first year of life. A $2000 savings was found for all Medicaid participants in birth center care compared to those with similar risk profiles in typical care.

1) The proposed changes for Oklahoma will require birth centers to be accredited by the Commission for the Accreditation of Birth Centers (CABC) to be eligible for Medicaid reimbursement.  Other states, including Minnesota, North Carolina, and Montana use CABC accreditation as a method of deeming either licensure or eligibility for Medicaid reimbursement. 

Accreditation is a high standard of quality that includes requirements including plans for continuous screening for risk factors, detailed plans for transfer, and ongoing review and quality improvement of care provided.  The Standards encourage good communication and collaboration between birth center providers and hospital providers to make the transfer process as safe and seamless as possible.

Because of the high standards of accreditation, AABC supports the policy of requiring accreditation instead of licensure with one concern. 

Some birth centers may feel they are not able to afford the costs of accreditation due to a high proportion of underserved or Medicaid patients. The AABC Foundation does offer accreditation scholarships if this is the case.

2) The proposed policy states that licensed CPMs and CMs will be reimbursed for low-risk births.  Will this policy cover the professional services of midwives in all birth settings, including the birth center, home, and hospital, depending on their scope of practice?  If yes, AABC supports this change. 

Certified Midwives are Master's prepared midwives who are educated to prescribe medications, provide primary care for women, and provide pregnancy, birth, and postpartum care in all birth settings.  Certified Midwives are certified by the American Midwifery Certification Board (AMCB), which is the same board that certifies Nurse-Midwives.  Certified Professional Midwives are educated and trained to practice in birth centers and homes and should be reimbursed by Medicaid in any setting where they practice within their scope.

3) Proposed policy changes state that licensed midwives will be reimbursed at 80% of the physician fee schedule for services within their scope of practice as defined by state law.  Federal law made Freestanding Birth Centers mandated Medicaid providers for pregnant women in 2010 (Section 1905 A).  This statute states that licensed midwives (or other birth attendants) providing services in freestanding birth centers recognized by the state must be paid by Medicaid.  (Section 1905. U.S.C. 42, 1396d).

Federal law also prohibits provider discrimination by Medicaid for coverage and participation based on different licensures if services provided are of a comparable high quality. (Section 2706, PPACA).

AABC recommends reimbursement at the same level for the same services provided, in the case of prenatal care and uncomplicated vaginal birth, regardless of provider type, be considered by Oklahoma. This reimbursement level would help midwifery provider services to be sustainable and accessible.  Midwifery-led care provides longer prenatal visits, which means that birth center midwives can see fewer patients per day in an effective, high-quality model of care that achieves healthier mothers and babies. If licensed midwives are reimbursed at 80% of the physician rate, they will be reimbursed at an even lower rate per patient for office visits in this proposed policy change.

AABC recommends the State of Oklahoma consider the same reimbursement for the same services, regardless of different licensure type.

Thank you once again for allowing us to comment on these proposed changes.

OHCA Response:

Thank you for your comment. The proposed policy changes allow coverage of services provided by licensed midwives within their scope of practice when performed in a birthing center, as directed by SB1739 of the 2024 regular legislative session.