Hey there! Chances are if you’ve landed on this page your insurance has declined to provide coverage at an in-network level for my services. *Ugh* I know, not ideal and not fun. Especially when you are learning to breastfeed and running on little sleep. In these circumstances patients will typically schedule an appointment with me at my out-of-pocket rate (HSA/FSA cards, credit cards, or debit cards are all accepted. Payment plans can, also, be arranged in advance of our appointment.). All is not lost!
What that means is after our appointment I will provide you with a SuperBill that you will then submit to your insurance for reimbursement. This can take a few weeks, but most families do see some level of reimbursement at their out-of-network rate depending on the health insurance plan. With me so far?
Let me explain a bit about what is going on. Unfortunately, there is an obnoxious loophole that allows health insurance companies in the United States to claim that they cover breastfeeding support and supplies as per the Affordable Care Act, even though they won’t allow IBCLCs to be in-network providers (and sometimes will refuse to reimburse families for their IBCLC visit altogether or make them work for the reimbursement).
So what can you do to advocate for your coverage?
Know your rights:
The Affordable Care Act states, “Health Insurance plans MUST provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth.” The only exceptions to this are state funded health care plans and grandfathered plans.
Advocating for your coverage
When contacting your insurance provider to check coverage, The National Women’s Law Center has a great script to follow available on page 8 here.
If your insurance company asks, my provider number is 1932798550. I typically use the procedure code 99404 and S9443 and the diagnosis code Z39.1.
Every health insurance company is different so you should ALWAYS to call the member services phone number on the back of your insurance card before you book a home visit.
When you get a human on the phone, ask them: what your policy covers for breastfeeding support and counseling, if they require you to see someone in-network, and if so, exactly who your in-network options are, if you have no in-network options, or they can’t give you a list of providers, ask them how much money they will reimburse you for obtaining breastfeeding support and counseling from an out-of-network provider, and exactly what their procedure is for submitting for reimbursement after seeing an out-of-network provider.
I’ve heard from my clients that some health insurance companies (like Harvard Pilgrim, Tufts, Fallon, and Blue Cross Blue Shield in Massachusetts) are great about reimbursing for IBCLC home visits, while other companies (*cough* United Health Care and Cigna *cough*) seem to automatically deny the first claim. I’ve even heard that certain companies make patients resubmit the claim 4 times before they’ll reimburse for the services.
If they deny your initial claim for reimbursement, call Member Services again and ask them where to send an appeal. Ask them if you need an appeal form that they provide you. The National Women’s Law Center has a Breastfeeding Toolkit here that you can download that includes a step-by-step guide for drafting an appeal letter to send to your insurance company with your superbill/receipt. If you have any problems or questions during this process, you can call the National Women’s Law Service directly at 1-866-PILL4US or email them at pill4us@nwlc.org.
Final Note
To all my new families out there, I know fussing with your insurance company is the last thing you want to do. But taking the time to do this when you are denied coverage will help pave the way for other families to receive the breastfeeding support they deserve. If for some reason your insurance company does now cover the cost for my services, I want to assure you that in being a self-pay patient with an IBCLC, you will be receiving the best breastfeeding support in your area. I am passionate about what I do, I care deeply about every family I work with and strive for excellence in my work. Please reach out with any questions or concerns!
Helping Shape the Future of Lactation Coverage
I have not had any contact with this law firm and I am in no way associated with them – but I am interested to see how this plays out. Unfortunately, it is going to take some really big action to change the way the health insurance companies are currently treating lactating parents, and if it has to be a lawsuit… then so be it.
If you have dealt with denial of coverage for lactation services or equipment, if you’ve had to pay out-of-pocket for breastfeeding help or supplies, if your insurance company has told you that they only cover lactation consultants in-network and yet don’t have any IBCLCs in-network (I’m looking at you, Blue Cross Blue Shield), or if your insurance company limited your breastfeeding support to only the hospital setting, please consider contacting them.