LACTATION COVERAGE AND THE LAW

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ACCEPTING HEALTHCARE FLEXIBLE SPENDING ACCOUNTS

SELF PAY CLIENTS

The Affordable Care Act requires that all new health plans cover lactation support and supplies without cost-sharing “for the duration of breastfeeding,” which means plans may not apply any co-payment, co-insurance, or deductible to these benefits. Insurance companies can impose some limitations such as where to obtain the equipemnt and requiring the purchase, rather than rental, of a pump.

Private insurance: The relatively few exceptions are “grandfathered” plans that do not have to comply. The most effective way to find out if your plan is grandfathered or not is to call your insurance carrier and to ask. All plans purchased on the Health Insurance Marketplaces must cover lactation support and supplies.

Medicaid: Coverage for lactation support and supplies will vary by state and by type of Medicaid coverage.

Military Benefits: TRICARE is finally covering lactation support and supplies. Be sure to check with your plan for specific details.

If you are having problems obtaining lactation benefits, visit www.nwlc.org (National Womens Law Center) or call them at 1-866-745-5487 

Where to Start?

  1. First determine if your plan is grandfathered or not. If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.

  2. If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out of network exemption (or gap exemption). Make sure to ask for an exemption for several visits since most cases require 2-4 visits and more complex cases can require 6 visits. Here is the information you need from me to get pre-approval:

    Provider Name: Rebeca Four

    NPI # 1710273859

    EIN # 45-1714293

    Address: 51 Newark Street, Suite 404 C, NJ 07030

    Phone: 201-657-1727

    Diagnosis Code: z39.1

    Procedural Codes: OFFICE: 99404 and S9443

    Modifier: OFFICE: 33

    Place of Service: OFFICE: 11

    Write the date, time and NAME of the supervisor or agent who tells you that you are covered. Ask them to note your file and if possible to send you confirmation of the conversation and the information they gave you regarding the coverage under your benefits.

    The Lactation Place, LLC Gap Insurance Policy: we do NOT accept assignment from any insurance carrier that we are not contracted with. You must obtain the gap exemption for you to get reimbursed. You must pay us our full fee then you can accept reimbursement up to the amount your carrier determines they will cover.

  3. If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.

  4. It can be useful to get a referral from your pediatrician and or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.

  5. POSSIBLE SCRIPT TO USE WHEN CALLING: If your pediatrician conceded to giving you the referral then make sure to start the script with this information.

    You: I understand that under the Affordable Care Act all plans are required to cover breastfeeding support and supplies without cost-sharing. Can you confirm that my plan follows this Federal guideline?

    Insurance Agent: NO, we don’t cover breast pumps or lactation consultants.

    You: Is my plan grandfathered?

    Insurance Agent: NO, your plan is not grandfathered, but we don’t provide this benefit.

    You: The healthcare law requires that you provide this benefit. Can I speak with a supervisor to make sure this is the correct information about this policy?

    Repeat these questions to the supervisor and insist that under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment [ for the duration of breastfeeding.”

IN NETWORK + SELF-PAY SERVICES

If your plan requires you to use in network providers, and your plan is not Aetna and you live in New Jersey, you will not find an in network provider except for 2-3 breastfeeding medicine doctors that are also IBCLCs but who are located in Central and South Jersey and who treat more advance clinical lactation issues and who will likely not have an appointment available within 48 hours. Insist that there is no in network provider within 25 miles and because they are required to cover preventive lactation services they must give you an out of network exemption. This last requires the following information from the lactation consultant: NPI number, Federal Tax ID, address and phone number and the diagnostic and procedural codes the lactation consultant will use to bill for your services. These extra steps are a pain but may be worth it if you can get at least partial reimbursement.

Appealing a Denial for Lactation Equipment (Breast Pump)

SAMPLE LETTER NO COVERAGE POLICY FOR BREAST PUMP (When you copy and paste this you may need to take a quick moment to adjust the format)

To Whom It May Concern:

I am enrolled in a [INSURANCE COMPANY NAME] plan, policy number [POLICY NUMBER]. I recently tried to purchase a pump through my health insurance. The Patient Protection and Affordable Care Act requires that my insurance coverage of this preventive service be with no cost-sharing. However, when I contacted [INSURANCE COMPANY NAME] about the coverage, I was told I could not get coverage of [BREAST PUMP REQUESTED]. 

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services which must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment [] for the duration of breastfeeding” (see attachment). 

My health insurance plan is non-grandfathered. Thus, the plan must comply with the women’s preventive services provision.

[INCLUDE THIS PARAGRAPH IF YOUR PLAN DOES NOT HAVE A CLEAR PROCESS TO GET A PUMP] My health care provider has prescribed that I use [BREAST PUMP REQUESTED]. The insurance plan has not established a process for me to obtain a pump, such as through a durable medical equipment supplier, and thus it remains an over-the-counter product for the purposes of my plan. As the FAQs on the preventive services (dated February 20, 2013) state, “OTC recommended items and services must be covered without cost-sharing…when prescribed by a health care provider.”  Accordingly, [INSURANCE COMPANY] must cover [BREAST PUMP REQUESTED] as required under the Affordable Care Act. 

LAST PARAGRAPH OPTIONS: (1) I have spent [TOTAL AMOUNT] out-of-pocket on [NAME OF BREAST PUMP], despite the fact that it should have been covered. I have attached copies of receipts which document these out-of-pocket expenses. [COMPANY NAME] must rectify this situation by reimbursing me for the out-of-pocket costs I have incurred during the period it was not covered without cost-sharing. Furthermore, [COMPANY NAME] must ensure breastfeeding support and supplies, including lactation counseling are covered without cost-sharing in the future by changing any corporate policies that do not comply with the Affordable Care Act. 

Or  (2) I am prepared to order [BREAST PUMP REQUESTED] when [COMPANY NAME] assures that I have coverage without cost-sharing. I expect that [COMPANY NAME] will rectify this situation and notify me within 30 days of receipt of this letter that [BREAST PUMP REQUESTED] will be covered without cost-sharing.

Sincerely,

[YOUR SIGNATURE]

Encl:

Frequently Asked Questions about the Affordable Care Act (Part XII) (available at http://www.dol.gov/ebsa/faqs/faq-aca12.html) Copies of Receipts Documenting Out-of-Pocket Costs

Appealing a Denial for Lactation Support

SAMPLE LETTER COVERAGE FOR LACTATION CONSULTANT (When you copy and paste this you may need to take a quick moment to adjust the format)

To Whom It May Concern:  

I am enrolled in a [INSURANCE COMPANY NAME] plan, policy number [POLICY NUMBER]. I recently tried to access lactation counseling that should be covered by my health insurance. The Patient Protection and Affordable Care Act requires insurance coverage of breastfeeding support and supplies with no cost-sharing. However, when I contacted [INSURANCE COMPANY NAME] about the coverage by [SPECIFY METHOD, PHONE] on [DATE], I was told I could not get coverage of [LACTATION COUNSELING] because [SPECIFY REASON, SUCH AS NO IN-NETWORK PROVIDERS]. 

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding” (see attachment). 

My health insurance plan is non-grandfathered and the plan year started on [PLAN YEAR DATE]. Thus, the plan must comply with the women’s preventive services provision. 

The insurance plan has not established a process for me to obtain in-network lactation counseling, as required by federal law. Federal guidance on the preventive services clarify that, “… if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.”

Since [PLAN YEAR DATE], I have spent [TOTAL AMOUNT] out-of-pocket on [LACTATION COUNSELING], despite the fact that it should have been covered during that time. I have attached copies of receipts which document these out-of-pocket expenses. [COMPANY NAME] must rectify this situation by reimbursing me for the out-of-pocket costs I have incurred during the period it was not covered without cost-sharing. Furthermore, [COMPANY NAME] must ensure breastfeeding support and supplies, including lactation counseling are covered without cost-sharing in the future by changing any corporate policies that do not comply with the Affordable Care Act. 

Sincerely, 

[YOUR SIGNATURE] 

Encl: 

Frequently Asked Questions about the Affordable Care Act (Part XII) (available at http://www.dol.gov/ebsa/faqs/faq-aca12.html)
Copies of Receipts Documenting Out-of-Pocket Costs

IT IS YOUR RESPONSIBILITY TO READ ALL OUR SCHEDULING, INSURANCE AND PAYMENT POLICIES

INSURANCE BILLING

YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY

IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE COMPANY IF YOU ARE COVERED FOR LACTATION SERVICES. CHECK UNDER NPI 1457969412 OR 1710273859. GET A CALL REFERENCE NUMBER AND WRITE DOWN THE DATE.

ONCE YOUR BABY IS BORN, WE HAVE TWO CLIENTS THAT WE PROVIDE SERVICES FOR AND WE BILL FOR BOTH FOR EACH CONSULT. ANY CONSULT THAT INVOLVES ASSESSMENT, RECOMMENDATIONS AND A CARE PLAN FOR YOUR BABY AND YOU WILL BE BILLED TO YOUR INSURANCE FOR EACH OF YOU.

AETNA MEMBERS/CLIENTS

Even if Aetna tells you that you are covered 100 percent, Aetna has drastically changed their lactation coverage since March 2024. They no longer cover six consults. They now cover six codes, TOTAL! Each consult is billed as two codes which means you, the parent, will have a total of three consults. Every “free” class you took online has deducted from your allowed of six TOTAL codes per year. They are no longer covering your child(ren)’s services as preventive, which means that their portion of the consult will go towards deductible or if they have met their deductible it will incur a small cost-share. Any ‘Patient Responsibility’ amount will be charged to the card you have on file. If your card is not valid, you will be notified and if the invoice is not paid, there will be a $100 processing fee added and your account will be forwarded for collection services.

If only your baby is covered under Aetna and you, the lactating parent, are not covered under Aetna, you MUST book a self-pay consult. If your baby is not on the lactating parent’s Aetna plan you must book the baby not on plan appointment and you must pre-pay the appropriate fee for each appointment.

We do not offer tele-health for Aetna clients.

CIGNA MEMBERS/CLIENTS

If your baby is not under your Cigna plan, you will have to pay a fee for their portion of the services for every consult. If only your baby is covered under Cigna, you will need to book and pay Self-Pay.

ANTHEM + BCBS MEMBERS/CLIENTS

It is your responsibility to check with Lactation Network to ensure that you are covered for lactation services. Every prenatal consult has a $35 booking convenience fee and every initial after birth consult has a $75 booking convenience fee both of which are due at the time of booking.

TELE-HEALTH DISCLAIMER

We only offer tele-health for Cigna, UHC, Self-Pay and Anthem + BCBS members approved through The Lactation Network. All tele-health consults are thirty minutes.

There are inherent limitations because a digital suckling assessment and a physical breast/chest can not be completed. Potential risks to the technology used for telehealth, are beyond the control of the provider, including interruption of connectivity, unauthorized access, and other technical difficulties.

CANCELLATION POLICY

Appointments canceled with less than 48 hour notice will be charged the FULL consult fee which is not covered by insurance. ALL fees for services are non-refundable and expire 60 days after the original purchase. The payment and no refund policy is SEPARATE from the cancellation policy. Refunds will NOT be issued once you book. Each client is responsible for all fees associated with each consult. Payment is charged at the time the appointment is scheduled. By scheduling your consult, you grant me permission to communicate with your insurance company regarding the services provided to you and to your child(ren).

Rental agreements: no refunds will be issued for any unused part of the rental terms. All equipment must be returned the day prior to the scheduled new charge in order to avoid being charged for a new rental term.

OFFICE CONVENIENTLY LOCATED AT 51 NEWARK STREET, SUITE 404 C, HOBOKEN

Providing in office lactation support to families in Hoboken, Union City, West New York, Weehawken, Kearny, Clifton, Rutherford, East Rutherford, Montclair, Fort Lee, Cliffside Park, Englewood, Closter, Alpine, New York City, Brooklyn and other surrounding areas Northern New Jersey