Lactation Coverage and the Law

The health care law (Affordable Care Act) requires that all new health plans cover breastfeeding support and supplies. These plans must cover breastfeeding equipment 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. While insurance companies must cover breastfeeding equipmentand supplies, they can impose some limitations such as requiring the purchase, rather than rental, of a breast pump.

The ACA 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 aslong as they are breastfeeding. Women may be limited to the providers in their plan’s network to receive this benefit withoutcost-sharing.

  • Private insurance: Most women who have health insurance through an employer are enrolled in plans that must provide coverage for breastfeeding support and supplies. The relatively few exceptions to this requirement are considered “grandfathered” plans and they do not have to comply. If you have a grandfathered plan you should have been notified. 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 breastfeeding support and supplies.

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

    Military Benefits: As is typical and NOT surprising of our government, TRICARE—health insurance for military families—is not required to cover breastfeeding support and supplies.

If you are having problems obtaining breastfeeding benefits, please visit www.nwlc.org or contact the National Womens Law Center for further assistance. You can also call them at 1-866-745-5487 .

I KNOW you should NOT be subjected to this kind of stress after having a baby but if we do not SPEAK UP then things will not change. You DESERVE support and you are paying for it through your insurance premiums.


Where to start?

  1. If you have private insurance, either through a plan you bought on your own or through your employer, you must first determine if your plan is grandfathered or un-grandfathered. If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.

  2. Call the phone number on your insurance card for member services. The person answering the phone is not the person making the decisions. If the person with whom you speak is unable to answer a question you have, you might want to ask to speak with a supervisor. If you are told that you do not have lactation coverage ask to speak to a supervisor. Let them know that you are aware that lactation is covered under the Affordable Care Act as preventive services, which means no co-pay or dedcutible.

  3. If you get your insurance through your job, and have an employer-sponsored plan, you may have a benefits administrator you should also call them to ask that they advocate on your behalf with the insurance company.

  4. It can useful to get a script or referral from your pediatrician for lactation support.

  5. The National Women’s Law Center has a great phone script that you can use when calling:

    You: Hi, I understand that under the health care law, all plans are required to cover breastfeeding support and supplies without cost-sharing. I’m calling to confirm that my plan is covering these services. Can you tell me if it is?

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

    You: Is my plan grandfathered?

    Them: 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.”

    (If your pediatrician conceded to giving you the referral then make sure to start this part of the script with this information). Also tell them that the American Academy of Pediatrics (AAP) recommends that all babies be breastfed for at least one year. (PEDIATRICS Vol. 115 No. 2 February 2005, pp. 496-506). When breastfeeding difficulties occur, the AAP recommends that mothers and babies be seen by an IBCLC. In addition, extensive research over many decades has proven that NOT breastfeeding results in significantly higher healthcare costs as a result of higher rates of maternal and child illness and disease.  For this reason, the APP recommendation for insurance reimbursements for IBCLCs services is a cost saving measure to insurance companies.

    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 information they gave you regarding the coverage under your benefits.


In Network and Out of Network 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 50 miles and because they are required to cover preventive lactation services they must give you an out of network exemption. This last may require information from your lactation consultant including their NPI number, Federal Tax ID, their address and phone number and the diagnostic and procedural codes the lactation consultant will use to bill for your services. It requires a few extra steps but it is worth it if you can get at least partial reimbursement.

More on this soon!


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