LACTATION COVERAGE AND THE LAW
ACCEPTING HEALTHCARE FLEXIBLE SPENDING ACCOUNTS
AETNA MEMBERS/CLIENTS
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.
YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY
Being covered does mean free! Despite what any Aetna representative may tell you, your coverage for lactation benefits is completely dependent on your individual plan, which is dictated by your employer. Even if Aetna tells you that you are one hundred percent covered for lactation, they may assign you a copay or a patient responsibility for which you are responsible to pay us.
We invest every possible effort to get your claim(s) fully covered and we have an extremely high success rate. We have been in network since 2013 and have literally the most excellent and knowledgeable billers for lactation, who are truly dedicated and committed to avoiding any client cost share. We use the proper and most conservative billing codes available that have the lowest risk factor of triggering any cost share. We have been using the same correct codes since 2013. Despite what the Aetna rep may tell you, our codes are correct. At the end of the day, Aetna holds all the power and they adhere to the benefits your employer sets!
Our situation is unique as healthcare providers. We have two clients, not one. We bill for both you and your baby because in ninety-five percent of the consults we assess and make recommendations and a care plan for two clients. The exceptions are when we do prenatal consults and for some weaning consults where it is strictly the parent only. If your consult includes any discussion, assessment, and care plan for your baby we will bill accordingly for both of you.
We use multiple codes per service date because this is standard practice and the only way to bill for the complexity and or duration of the service provided. Using multiple codes does not bill multiple consults per date. This is incorrect and a tactic that Aetna uses to pin the client against the provider and to get away with not paying.
Any patient responsibility or copay that Aetna assigns you after we exhaust all requests for reprocessing is your financial responsibility to us and will be billed directly to the credit card you have on file with us unless you indicate you want to use a different form of payment within 24 hours of the issuance of your invoice in which case that new form of payment will be billed.
Aetna is in the business of making billions in profit per year. We are in the business of providing expert, culturally competent, compassionate infant feeding and lactation support to families and for this, we must be paid.
Thank you for the trust you extend us and for the opportunity to support you.
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?
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.
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.
If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.
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.
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
AETNA MEMBERS/CLIENTS
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 FOR YOU WILL BE BILLED TO YOUR INSURANCE FOR EACH YOU AND YOUR BABY.
YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY
It is your responsibility to check with Aetna to ensure that you are covered for lactation services. Even though Aetna may tell you that you are covered 100 percent, it is possible that some Aetna plans may assign you a ‘Patient Responsibility’ fee which will be charged to the card you have on file. 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.
Aetna typically assigns patient financial responsibility to tele-health consults which varies from plan to plan.
Your claim(s) will be submitted to Aetna for payment. If Aetna applies any portion of the fees towards a deductible or otherwise charges a coinsurance payment your card on file will be charged for the patient responsibility amount. By scheduling your consult, you grant us permission to communicate with Aetna regarding the services provided to you and your baby(ies) and you agree to our payment policies.
CIGNA + BCBS MEMBERS/CLIENTS
YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY
It is your responsibility to check with Lactation Network to ensure that you are covered for lactation services.
TELE-HEALTH DISCLAIMER
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 tele-health, are beyond the control of the provider, including interruption of connectivity, unauthorized access, and other technical difficulties.
LANGUAGE
If we have used any language that has caused you harm or if there is a better option that we could use, please let us know.
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.