Executive Director of CAPPA’s Lactation Programs
As you may, or may not, know with the passage of the Affordable Care Act (ACA) women now can receive coverage for lactation services through their insurance provider. While the time has come for these services to be seen as preventative and supportive care, the Affordable Care Act unfortunately did not make enough specifications on exactly what should be covered. The law states that “Payers must cover, at no cost to the patient, ‘comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment’. Here is a link to the verbiage on the HRSA website: http://www.hrsa.gov/womensguidelines/
What exactly does this mean? What does comprehensive lactation support mean? Who qualifies as trained providers? Why only cover rental of breastfeeding equipment? When was the last time you heard of a mother renting a nipple shield or a Supplemental Nursing System? Must all insurance companies pay for these mysterious covered services? I have been attending webinars and state health department meetings and what I have gleaned from all of the discussion is that the resolution for understanding and interpreting the ACA in terms of lactation is still in its infancy.
Let’s start with who has to pay for these services. The Affordable Care Act generally covers commercial insurance contracts. Whether Medicaid covers these services or not is basically up to the state. They have to elect to cover USPSF (US Preventative Services Task Force) preventative services. If they have decided to do so, then lactation coverage should be a part of that. Military services are also exempt from the recommendations in the ACA. Every insurance company also gets to decide how they interpret the ACA language. Many states have decided to create guidelines for insurance payers to use for interpretation on the ACA. The United States Breastfeeding Committee and the National Breastfeeding Center have created a Model Policy: Payer Coverage of Breastfeeding Support and Counseling Services, Pumps and Supplies. Most states have not modeled this “model policy”. Here is a link to that model policy: http://www.usbreastfeeding.org/Portals/0/Publications/Model-Policy-Payer-Coverage-Breastfeeding-Support.pdf
For insurance payers, the language in the ACA has created significant confusion. There are no clear directives about exactly what services are to be covered, at what rates, or even who should be providing these services. Most of the payers are also unfamiliar with the needs of lactating woman and do not have a grasp on what types of lactation equipment is needed in different circumstances. For example, if a woman has baby that she is exclusively expressing her milk for, she requires the use of a hospital grade breast pump, NOT a double-sided electric consumer pump. Furthermore, payers do not have a clear understanding of the circumstances in which a woman requires lactation services and when.
Here are some of the challenges that have mothers have been encountering.
When mothers call their insurance companies to find out how they can access their breast pumps they get the following responses:
· They must get their pump (of the insurance company’s choice) through a Durable Medical Goods Supply. These pumps often take weeks to be delivered. This is a problem twofold. One: it may be an inappropriate pump for the mother’s situation. Two: They may not get the pump in time for their needs.
· They have to purchase the pump and submit a receipt. They may or may not receive full reimbursement.
· They are simply mailed a breast pump from their insurance company. It may be an ineffective hand pump or an inexpensive double electric.
· Side note: There have also been known cases of insurance fraud. Women requesting pumps and then selling them on EBay and Craig’s List in their unopened packaging
Another challenge mentioned above is determining who is considered a trained provider. Commercial payers must insure that the professionals they pay are credentialed and follow certain rules and regulations. For most insurers this means that they will only cover licensed care providers or create standards for non-licensed professionals. Most insurance companies choose to reimburse (at least at highest rates if at all) their own credentialed professionals or in network providers. These providers must have their qualifications evaluated, meet certain criteria, confirm that they meet professional conduct and competence, and have their training, certification and licensure reviewed. The challenge (and also the opportunity) with this is that many lactation support providers are not licensed.
The International Board Certified Lactation Consultant is an internationally certified professional but not required to get licensure to practice in the 50 states. Many states have been considering licensure for IBCLCs, however at this stage it is not mandatory, nor even possible. The Certified Lactation Educator is also a certified but not a licensed professional. Many insurance companies have decided to work their way around this by simply contracting with RN/IBCLCs only for all services (RN’s do have licensure).
However, there are other professionals who are trained and certified to teach breastfeeding classes and run support groups, such as CAPPA’s CLE. This could potentially mean that professionals like CLEs could finally receive reimbursement for their services! Just as we are finally seeing doula services starting to get reimbursement, now is the perfect opportunity to start inquiring and talking to commercial payers about reimbursement for breastfeeding education services provided by CLEs. As the ACA dissemination is in its infancy, now is the time for breastfeeding professionals to make their voices heard and talk to the insurance company’s and state health departments who are making suggested guidelines.
Let’s look at on commercial payer’s response to the ACA:
Aetna: They are allowing IBCLCs to provide lactation support services and have identified the codes that they can use for reimbursement. They do require the use of in network IBCLCs. They cover the purchase of a pump through Durable Medical Supply and they also cover rental of a hospital grade pump when medically necessary. Below is the policy found on Aetna’s site (http://www.aetna.com/cpb/medical/data/400_499/0421.html )
“Aetna considers rental of a reusable breast pump medically necessary durable medical equipment (DME) when either of the following criteria is met:
- For the period of time that a newborn is detained in the hospital after the mother is discharged; breast pump rental is not considered medically necessary once the newborn is discharged; or
- For babies who have congenital disorders that interfere with feeding, a breast pump is considered medically necessary for up to 12 months of age.
Note: The following policy applies to new health plans and non-grandfathered plans that are currently subject to DHHS requirements for coverage of breast pumps, with coverage beginning in the first plan year that begins on or after August 1, 2012 (please check benefit plan descriptions):
- Aetna considers purchase of a manual or standard electric breast pump medically necessary during pregnancy or at any time following delivery for breastfeeding.
- Aetna considers purchase of a manual or standard electric breast pump medically necessary for women who plan to breastfeed an adopted infant when the above listed criteria are met.
- Aetna considers rental of a heavy duty electrical (hospital grade) breast pump medically necessary for the period of time that a newborn is detained in the hospital.
- For women using a breast pump from a prior pregnancy, a new set of breast pump supplies is considered medically necessary with each subsequent pregnancy for initiation or continuation of breastfeeding during pregnancy or following delivery.
- A replacement manual breast pump is considered medically necessary for each subsequent pregnancy, for breastfeeding during pregnancy or following delivery.
- A replacement standard electrical breast pump is considered medically necessary for subsequent pregnancies, for breastfeeding during pregnancy or following delivery, for members who have not received a standard electric breast pump within the previous three years or if the initial electric breast pump is broken and out of warranty.
- Aetna considers purchase of heavy duty electrical (hospital grade) breast pumps not medically necessary.”
Here is what lactation professionals need to know. Encourage your families to communicate early on with their insurance companies. Get actively involved in your state breastfeeding coalitions and work with state health department to ensure that access to lactation services is reasonable and include support professionals who are certified for those services. Finally, let mothers know that services are covered and be proactive in gaining access to these services.
While the ACA provide far from perfect lactation support, it is a step in the right direction in recognizing the fact that lactation support is PRIMARY preventative healthcare. It is also an amazing opportunity for lactation professionals to have their voices heard. Commercial payers are ready to listen and they need guidance. It is time to build some bridges and make your voices heard!