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Will insurance cover my lactation consultation?

Parents ask me all the time- Will insurance cover my lactation consultation?

Will insurance cover my lactation consultation? Well, that depends……….on a lot of things! So, here is my best guidance on how to get your visit covered. Having provided lactation care now for around 20 years – alot has changed over the years. Certainly, the Affordable Health Care Act has been instrumental in pushing insurance companies to cover lactation care. Over the years, I have spent countless hours on the phone with insurance companies advocating for my clients. I have talked with numerous insurance company reps, supervisors and beyond. This is what I have learned, been told and surmised from my experience.

If you have Aetna – you are lucky!

First, if you have Aetna insurance – then YES! You are one of the lucky ones – Aetna typically covers somewhere around 6 visits. Even if you have Aetna it is always smart to call and confirm with them that this is true. They sometimes assign co-pays or deductibles but for the most part they easily cover lactation services.

Other insurance companies- will they cover my lactation visit?

For all other insurance companies – it is more of a crap shoot. This includes United Health Care, Cigna, Connecticare , and Blue Cross and Blue Shield (this varies across the individual states).

Will insurance cover my lactation consultation?

The AHCA Affordable Health Care Act does state that you are entitled to lactation coverage in or out of network with no cost sharing! But, the honest truth is most insurance companies make you jump through so many hoops just to get coverage – they make it really hard! However, it CAN be done.

The insurance company will tell you that they do cover lactation visits as long as you see someone at your doctor’s office or at the hospital where you delivered to receive this care. However, not that many doctor’s offices (at least in our area) actually have an IBCLC (International Board Certified Lactation Consultant) to provide this care. Be sure if your doctor’s office does say they have a lactation person on staff that it is an IBCLC (International Board Certified Lactation Consultant). Some offices will have a person who has taken a week long course in lactation. They may be able to help you with basic breastfeeding problems. However, they may not have the training that is necessary to troubleshoot more difficult breastfeeding issues. Also, the doctor in most cases doesn’t provide this care, either. Your doctor, PA-C, or APRN may actually be the one referring you to the IBCLC. It is the same story with hospitals. Many hospitals do not have an outpatient clinic where families can return to receive this care.

WHAT DO YOU DO NEXT? Will my insurance cover my lactation visit?

My insurance company is saying they cover lactation care IF I receive it at my doctor, PAC, APRN or hospital. However, they don’t provide lactation care!

Here are my best tips for getting your lactation consultation covered by insurance!

Important tip: When you call the insurance company each time ask for a reference number for your call and the name of the person you are speaking with and document it!

FIRST STEPS – Will my insurance cover my lactation visit?

  1. Start by calling your insurance company and saying, ”I am a new parent and just want to confirm that my upcoming lactation consultation will be covered by my insurance. I know that the AHCA (Affordable Health Care Act) states lactation visits are covered in or out of network.
  2. If they say, ”YES, as long as you see your doctor for that care or go to the hospital where you delivered” what should you say? Reply with ”I cannot access care at my doctor or hospital since they do not provide that service. In fact, my doctor or hospital are the ones referring me to this IBCLC “. Give them the name of the provider you want to see or have been referred to with their Tax ID (if possible).

NEXT STEPS – Will my insurance cover my lactation visit?

  1. Next, they will check to see if the IBCLC is in network. Most likely they will tell you that the IBCLC is not in network. This does vary across the country but in general most insurance companies besides Aetna do not allow IBCLC’s to join their networks. Here is where the problem lies.
  2. It is helpful to ask the IBCLC you are scheduled with for their Tax ID, NPI and the codes they may bill before you call the insurance. Typically the insurance company wants to know that information. Anything you can do to keep from having to call the insurance company back many times keeps you from ”LOSING YOUR MIND”!
  3. Once the insurance company checks to see if this IBCLC is in network they usually say -“ NO! It won’t be covered because the IBCLC is not in network.” Don’t take no for an answer! Stand your ground. Ask to talk to a supervisor.
  4. State, ”I know that the AHCA statute states that lactation visits are to be covered in or out of network with no cost sharing to me! ” Ask how you can make this happen since you know the law.

LAST RESORT! Getting no where fast? Here’s what to say and do next to get your insurance to cover your lactation visit. Don’t give up!

  1. If you get no where with them – pull out the big guns! Ask for them to initiate a gap exception or sometimes they call it an ”in for out exception”. This simply means if there is no one IN network – then the insurance company needs to provide the service OUT of network. They usually will tell you they will initiate this request and it will take 2 weeks or so to get it approved.
  2. AGAIN – STAND YOUR GROUND! Tell them, ”I have a newborn who is having trouble feeding and I need help NOW! I can’t wait for 2 weeks for approval.” Ask for them to expedite this request – they can – but you have to ask.
  3. As stated above – don’t forget to ask for a reference number (they record these calls) and the name of the person you are speaking with and document it. This way if you have continued trouble with coverage you have the documentation of your conversation with the insurance representative.

Getting coverage for your lactation visit is your right!

Insurance coverage for your lactation consultation is possible!

As an IBCLC there is nothing more I want than for you to have your lactation visit covered by your insurance! I submit your claim to your insurance company for you at no charge! However, the fight once submitted (except for Aetna since I am in network with them) is yours!

Comment below with your experience with getting your visit covered by insurance! Were you successful? What did you do that is different than the above? We would love to hear from you!

Looking for more information about insurance coverage for your lactation visit? The National Women’s Law Center has some great info for you.

Have questions regarding the AHCA and it’s protections for breastfeeding?

Want more information about the AHCA and lactation consultants?

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Patrice Jones

I have 20 years of helping moms as an IBCLC and also 30+ years of experience as a physician assistant working with babies and families. I am also the mother of three breastfed children and understand the pressures of working and being a mom. I get the total exhaustion you feel but the commitment to do everything you can to give them the best.

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