Serving Westchester, Putnam, NYC, and Brooklyn

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Barbara Ryan
International Board Certified Lactation Consultant

Navigating Insurance

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Lactation Coverage and the Law

The Affordable Care Act requires that all new Heath plans over breastfeeding support and supplies. It covers prenatal and postnatal lactation support and counseling.  It is important to contact the individual insurance company as some companies may limit the breastfeeding mother to providers that are in their plans network.  The exception can come from if the plan is a grandfathered plan.  These plans do not have to comply.  To find out if your plan is grandfathered, call the insurance company.  All plans that are purchased on the market places must cover breastfeeding support.  For Medicaid, it varies but state and coverage, and lastly military insurance is not required to cover breastfeeding support.  


If you are having trouble obtaining breastfeeding support visit www.nwlc.org or contact National Women’s Law Center for change at 1-866-745-5487



How to make sure your covered:


PRIVATE INSURANCE: First call and find out if you are un-grandfathered or grandfathered.  If it is grandfathered you will not have lactation coverage.  

If you are not in-grandfathered, call member services, ask about your plan and lactation converge.  If the person on the phone can not answer your questions, or you are told you do not have lactation coverage, ask to speak to a supervisor.  When the supervisor comes on the phone state that you know under the Affordable Care Act, that lactation services under preventive services are covered and which means no deductible or co-pay.  


Some companies have an insurance liaison person who you can ask questions to as well. They also can be your advocate if needed.


Referrals are not necessary, but if having trouble it can’t hurt.  You can obtain this referral from your pediatrician, midwife, or OB/GYN.


Having a script in place also may help.  Here is an example put out by the The National Women’s Law Center:


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


INSURANCE: “No, we do not cover lactation consultants.”


YOU:  “Is my plan grandfathered?”


INSURANCE: “No, your plan is not grandfathered, but we don’t provide this benefit.”


YOU:  “The health care law requires that you provide this benefit.  Can I speak with a supervisor to make sure this is the correct information about this policy?”


Once supervisor is on phone, go through the same questions again.  If you are still having difficulty:


YOU:  “Under 1001 of the Patient Protection and Affordable Care Act, which amends the 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 plans years starting in August 1, 2012 includes comprehensive lactation support and counseling and costs of renting and purchasing breastfeeding equipment for duration of breastfeeding.”


If you have a referral, mention you have the referral as well.  


Also to add that the American Academy of Pediatrics recommendations that all babies be breastfed for at least one year.  When breastfeeding difficulties occur, the AAP recommends that mothers and babies be seen by an IBCLC.  


At the end of conversation write doe the date, time and name of agent/supervisor who tells you that you are covered.  Ask them to note your file and if possible send you a confirmation of the conversation which will include the coverage under your benefits.  




IN-NETWORK AND OUT-OF-NETWORK SERVICES:


Some plans may state that you must use in-network providers.  They are far and few and if you do happen to find one, they most likely can not see you right away and you will need to travel to their location.  Tell the insurance company that there are no in network providers near me.  You ask asking for a network exception as you must go out of network.  They may want the name, NPI, tax ID, address and phone number, diagnosis codes and procedure codes from the lactation consultant you plan on seeing.  This part is worth it and you are more than likely to get get the visit covered or at least partial reimbursement.  


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.