Standard and CNM — The Bump
Military Families

Standard and CNM

Hello! Has anyone switched from Prime to Standard for care? I would definitely prefer a midwife CNM for annual appointments and prenatal/delivery, but it won't be fully covered at an offbase provider if I'm still on Prime is this correct? Just wondering about other's experiences, copays, etc. I keep reading mixed information. Thank you!

Re: Standard and CNM

  • It will be covered on Prime if you get referred out. At some places, everyone is referred out. At others, very few are referred out.

    If you can't get a referral, Standard is definitely an option. I saw a CNM for my pregnancy with DD while on Standard. Everything was covered except for a small daily rate for my hospital stay. I love the convenience of Standard.

    You do need to be aware that if you switch to Standard and your sponsor's rank is E5 or higher I think... Or is it E4 or higher?, you'll be locked out of Prime for a year.
    Hilary
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  • I switched from prime to standard over the summer knowing we would be TTC when H got home from deployment.  We live in a such a huge military area that I did not want to be dealing with medical here or delivering in the military hospital that is about 40 minutes away from us.  I absolutely love my OB I found and the hospital I'll deliver at now is not even 10 minutes from my house, and I feel more comfortable there than I ever did at base med.  

    The copays aren't terrible.  When you consider paying nothing with Prime then yes it can seem high, but to me it's worth it.  I had one bill for about $130 after my first visit, but since then it's only been $10-20.  And once you hit your cap for the year you are done with copays, which will happen after delivery.  Also, the convenience for other things is fantastic to me too, like just being able to go to urgent care when needed instead of waiting for an appt.

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  • I really don't know why anyone WOULDN'T go with standard.  The catastrophic cap is only $1000.  IF and I mean IF you make the cap, it would break down to less then 100/month.  In the civilian world, premiums ALONE (not including copays) are often as much or more then that. I had extensive medical care last year and didn't even make the $1000 oop cap.  

    We live in a large city, and so far, I haven't found a single provider I'm interested in that isn't covered by TriCare.  Additionally, you don't have to wait for referrals from a pcm.  You can go anywhere you want, any time you want.  I used to see a CNM and she was covered by TriCare.   

    TTC since Aug 2011, RE since May 2012. Dx: PCOS,endo, postprandial hypoglycemia DH: SA 1 - low everything, 2- low everything, 3 - good, but WBC, 4 - lost and/or damaged at lab, 5 - low everything July - Letrozole + TI = BFN Aug - letrozole #2 + TI = BFN Sep - NEW RE!! YAY!!!! Move to IVF w/ICSI - ER on Nov 28 - 34 eggs! 2 day report - 26 successfully fertilized! 13 of 26 frozen at 3 days. 5dt of 2 best remaining eggs! BFP on HPT 6dp5dt Beta #1 10dp5dt-471 Beta #2 13dp5dt - 1250
  • I switched to standard with DS so that I could see a CNM, Once you get pregnant the provider confirms it and then maternity care is 100% covered by a maternity global authorization code. The only cost to you will be 16 dollars and some change per day for the hospital stay when you deliver. The plus side to this is when you deliver, your child is automatically covered under prime for 60 days but you dont need any referrals to get him seen by a pediatrician until he or she can be enrolled into DEERS.

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  • Thanks SO much! So when I switch, I'll need to go to the Tircare website and make sure the civilian CNM is authorized/in network? Or can any CNM be covered? Sorry for the questions, I've had a LOT of Tricare issues, so just want some real experiences and advice!
  • Does the CNM you're interested in have a website?  I would look at insurance info on the website if so, or even try calling around to see if you can find one.  You can search on Tricare's website for providers as well.  Make sure do the network and non-network provider searches to get more options.  You'll pay less with network providers, but will probably get more options with non-network ones.  

    https://www.tricare.mil/mybenefit/ProfileFilter.do;jsessionid=QN2YWKpk4qFW2Q1hNwJGYJPlWFnnTqLLY3JnSbL9GRwg473jPNxJ!610849042?puri=/home/Medical/FindingAProvider

    For me personally I had just researched OB's in my area and reviews for them.  I saw great reviews for this OB office, and then checked their website and saw they accepted Tricare.  They are a non-network provider but are worth the little bit of extra money for me without a doubt.  

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  • I saw an out of network provider and still only paid the daily hospital stay during my delivery.  However, if you choose an out of network provider and are seen for anything not pregnancy related (sore throat, etc) you will pay the 20% co-pay vice the 15% for in-network.  You just need to be sure that your provider will bill to Tricare on your behalf. 
  • Any certified nurse midwife is covered. a nm or just m is not.

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  • You're right but just want to clarify in case someone else searches this thread for information! There are 3 types of midwives and Tricare only covers one. CNM certified nurse midwife is recognized and covered under Tricare, just like an OBGYN. CPM certified professional midwife is NOT recognized as a provider. LM lay/licensed midwife is not, either.

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  • I'm on Prime and I see a group of CNMs. There are OBs as well but I only see the midwives in the practice.
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  • when I got pregnant I switched from prime to standard. prime WILL coer CNM, but only the ones at the Military facility unless they don't have room for your care(which RARELY happens on most large bases) because with prime they have "right of first refusal" you can try to be referred out, they would do that for my fertility treatment, but refused to do so for my prenatal care. I was very specific about what OB and midwife I wanted to see and wanted to go to the research hospital that is baby friendly in my area so it was worth the extra cost for me.

    Here's the difference: 

    Prime= everything is covered 100%

    Standard= global maternal health costs you $25 for one day in hospital or $16/day for more than one day in hospital + anything NOT maternity related you pay 20%, up to a yearly cap of $1000

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