Insurance Coverage

Worth the Fight!

These are benefits you paid for, so hold your insurance company responsible. 

As of August 1, 2012, breastfeeding support and equipment is covered by health insurance companies at 100%. 


That means no "cost sharing" -- you pay NO co-pays and your deductible does not need to be met to get your consultation covered by insurance.

 

This support continues for the duration of your breastfeeding relationship -- not just during your hospital stay, not just in the first few weeks.

Call the number on the back of your insurance card or visit their website to search their provider network for lactation support.  Only a couple of insurance companies currently have local IBCLCs in-network.  If your insurance company does not have local providers in its network to offer qualified lactation counseling, you must be able to go out-of-network, the service must be covered with no cost-sharing (i.e. no deductibles, no co-pays).  It's called a "gap exception".

 

I am not contracted with any insurance companies at this time, so I take payment at the time of the booking or at the end of the consultation, your choice.  I accept cash, check, debit card, credit card, HSA, or PayPal.  I give you two copies of my receipt that include insurance codes and all of the information needed for your insurance company to process your claim, but unfortunately I can't guarantee reimbursement.


I suggest calling your insurance company before our visit, the phone number should be on the back of your insurance card.  The National Women's Law Center even created an easy to follow script for mothers to use when talking to their insurance company, on page 8 of their Breastfeeding Toolkit.  

 

Sometimes your insurance company will ask for a procedure (CPT) code and a diagnostic (ICD-10) code; I usually use the codes 99404-33 for the procedure code and Z39.1 for the diagnostic code.

If your insurance company does not offer any breastfeeding support in-network:

Federal guidance makes clear 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.”1 If your insurance company does not have providers in its network to provide breastfeeding equipment or lactation counseling, you must be able to go out-of-network, the item or service must be covered; and covered at no cost-sharing. 

If you have been denied coverage for your claim:

 

The National Women's Law Center (NWLC) has assembled a helpful Breastfeeding Toolkit full of excellent information on how to work with your insurance company if they denied your claim.  Go to page nine of the PDF:  Breastfeeding Toolkit

 

Because coverage of lactation services is relatively new for many insurers, some companies are still sorting out what to cover, and confusion is common. These suggestions may help if you have difficulty getting reimbursement:
 

  1. If the insurance company calls to tell you anything at all about why they are not paying, politely tell them to send it to you in the mail. Do not try to educate them and tell them that it is mandated by the Affordable Care Act (ACA) / that it is mandated by law. They have been trained otherwise.
     

  2. When you receive your statement from the insurance company, read the denial codes for the claim.  Occasionally a claim just needs to be resubmitted under the mother's name instead of the baby's, or vice versa, or more information is needed in order to process the claim.  Some companies may ask for a referral from your pediatrician or ObGyn.
     

  3. When you appeal a claim, make sure to include the superbill, and this appeals letter.  Feel free to personalize the appeals letter with information such as:

a) The reason you sought help, especially mentioning if your pediatrician or another healthcare provider referred you.

b) Anything you were told on the phone by the company.

c) If they failed to give you a list of IBCLCs that would be covered.  

 

4.  Now it goes to the second level where the claim may be denied again.  Repeat.  The third time you send in copies of the receipt, the rejection and a snippet of the ACA where it says all counseling and supplies are covered (because breastfeeding is preventive care and that's what the ACA is focused on).  When you send it in the third time, you reach the "decision-maker" who knows very well that it is mandated.

 

5.  If you feel that your insurance company is still not complying with the ACA requirements, or handling your claim appropriately, consider complaining in writing to the State Insurance Commissioner, and notify your insurance company of the complaints you're filing, to pressure them to comply to the law:

 

Consumer Affairs Division

Arizona Department of Insurance

2910 N. 44th Street, Suite 210

Phoenix, AZ 85018-7269

Or submit a Request for Assistance form 

(https://insurance.az.gov/sites/default/files/documents/files/Request%20for%20Assistance%20Form%20%282%29.pdf)  

and email to consumercomplaint@azinsurance.gov

 

Also file a complaint with the National Women's Law Center:  http://action.nwlc.org/site/PageServer?pagename=coverher

WHAT PEOPLE SAY

— Ciji and Cooper

“Without her her, I believe I would have quit breastfeeding my son, and I'm so glad I didn't allow that to happen.