This is the #1 question that moms have. In the law of the land (aka the Affordable Care Act, #thanksObama), it is your RIGHT to have access to lactation counseling without cost-sharing for as long as you are breastfeeding. According to the National Women’s Law Center, the health care law requires all new health plans to cover “comprehensive prenatal and postnatal lactation support [and] counseling.” This means that breastfeeding mothers have health insurance coverage for lactation counseling without cost-sharing for as long as they are breastfeeding.
Many moms don’t know that they have access to this amazing resource to help support them reach their breastfeeding goals or figure out what to do next if they encounter any issues. This post is the first in a series addressing insurance coverage for lactation support. Today’s post will present a general overview of the process but watch the space for posts focused on specific insurers.
The usual process
- Call your health insurer to see what is covered and what is not covered (see questions to ask below!). Or if you’d like, consider emailing them directly or even chatting online with a representative!
- When you are checking with your insurer, ask them if they require referral documentation from your physician. Also, you may need to ask your IBCLC what codes they cover. As an example, here are some commonly used codes by lactation consultants:
- HCPCS Code S9443 face-to-face lactation class
- CPT Code 99404 preventive medicine counseling
- CPT Codes 99341-99350 home visit
- CPT Code modifier 95 for “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system”
- ICD Code Z39.1 for the “encounter for care and exam of lactating mother”
- Attend your appointment
- Pay with a credit card or FSA/HSA to your lactation consultant (I know, not ideal. It is a similar process as the dentist, which is frustrating)
- Get the superbill from you lactation consultant
“I had to call them like fifteen thousand times to get to the one person who knew what I was talking about, get some sort of pre-authorization letter for I think it was six visits, and then submit the invoice after as UHC had zero IBCLCs in network.”– Quote from a mom recently trying to get through the insurance reimbursement process for her lactation support services
But what do I ask my insurer?
So let’s break this down: If you’re using insurance, you should call your health insurer ahead of time and ask the following questions (also check out the FAQ where I define what the heck these terms mean!). They will generally honor what they told you on the phone if you can prove it, so make sure to write this down! Here’s a link to a downloadable reference sheet:
- Is lactation support covered? (virtual and/or in person)
- Is this provider covered? FYI – If they aren’t then they are out-of network and will often still cover it.
- Do I need a pre-authorization?
- Is there a copay/coinsurance?
- Does my deductible apply?
- What is the process for reimbursement?
- Is there a filing deadline for sending in the reimbursement?
Tip: make sure to ask for the right/most direct call number and write it down so you can refer back to it if you need to appeal.
Okay, now health insurers try to get around the ACA by saying they cover it but not having any in network providers and making you jump through hoops if you want to use coverage (coughs Cigna).
Health insurers currently covering tele-lactation support:
Aetna: They cover 6 tele-lactation support consults in-full. (Side Comment: It seems like Aetna is furthest along. Way to be Aetna!)
Blue Cross Blue Shield: Depends on the state, but BCBS MA covers in full.
Cigna: They will cover lactation support, but you need to submit a form in advance and get authorized before the appointment to go out-of-network. Ugh! Not cool Cigna, not cool.
United Healthcare: Honestly, United Healthcare is one of the hardest to work with, but never fear!, they will reimburse. They will ask for a letter of necessity from your doctor, so make sure to ask for one of these from your physician.
There are OH SO MANY MORE, please shoot me an email at email@example.com if you can share if your insurer did or did not cover and I will add them to the list!
Wait, what? Lactation Support is Covered by the Affordable Care Act!
Heck yeah! According to the National Women’s Law Center “The health care law requires all new health plans to cover “comprehensive prenatal and postnatal lactation support [and] counseling.” This means that breastfeeding mothers have health insurance coverage for lactation counseling without cost-sharing for as long as they are breastfeeding.” Many moms don’t know that they have access to this amazing resource to help support them reach their breastfeeding goals or figure out what to do next if they encounter any issues.
If my IBCLC is not in-network will they still get covered?
YES! I know so.many.moms that never went through the process of submitting their claim because they assumed that if they are not in-network, then they wouldn’t get reimbursed (or worse – moms that didn’t get a lactation consultant at all because it was cost prohibitive and IT IS YOUR RIGHT according to the Affordable Care Act to reserve reimbursement for lactation support!). You need to submit a form to your insurer (see one example here).
What do all of these health insurance terms mean?
Codes: These are an agreed upon set of numbers and letters that physicians and insurers use to label diagnoses and procedures.
Copay/coinsurance: The fixed amount of money you must pay out of pocket for a service as defined by your insurance after you have reached your deductible. (For example say the copay for an office visit is $20 your deductible is $1000 and your bill was $200. If you’ve already paid your deductible then you only pay $20; if you haven’t you would pay any/all of it to reach the deductible).
Deductible: The amount of money you have to pay before your health insurance begins covering costs. You must pay 100% of costs up to deductible before insurance kicks in.
In-Network: a set of providers that have a contract/relationship with the insurance company. These are usually searchable and identified on your insurers website.
Out-of-Network: any provider that is not part of the in-network.
Pre-authorization or prior authorization: a process deeming that a service or treatment is medically necessary. It is required before the insurance company will agree to cover certain services, though it is not a guarantee that any/all expense will be covered. For in-network providers, your doctor will usually seek approval; For out of-network providers, you are responsible for seeking approval.
Superbill: This name always cracks me up. There is nothing super about it, except for the fact that it is an itemized form. It is used by healthcare providers to detail services provided to a patient. It is the main data source for creation of a healthcare claim, which will be submitted to payers for reimbursement.
One last thing
The insurance process is really specific to each plan, so we would love to hear from you about how your plan differed, if we captured anything incorrectly, or if you have any juicy nuggets for us to add to this post. Hopefully, we can crowdsource feedback to help support parents everywhere getting their lactation support services reimbursed. Feel free to add a comment below or email me at firstname.lastname@example.org and I will update the blog with your insights!