The Affordable Care Act (ACA) also commonly known as “Obamacare” has been a law for over 10 years already, but few people actually know what benefits are included in this legislation.
In fact, according to a survey conducted by Byram Healthcare that appears in a US News & World Report article:
“82 percent of expectant mothers do not know their breastfeeding rights under the Affordable Care Act.”
For example, do you know that mothers under most commercial health insurance plans are entitled to a breast pump, free of cost? It’s true. Did you know the same thing applies for lactation support services? It’s also true and much less known.
If you have a health insurance plan through:
You might be asking, “What do you mean free lactation support for the entirety of your breastfeeding
Well, let’s break it down in further detail. Within the Affordable Care Act, there is a requirement that all commercial health insurance plans cover “women’s preventative health services” free-of-charge. Due to the numerous medical benefits for both mothers and their children stemming from lactation, breastfeeding support is covered under “women’s preventative health services.”
This means that you can’t be charged:
Like we said, lactation support is free-of-charge. So, take advantage of it and hire a Lactation Consultant for extra assistance! After all, you are already paying for it through your monthly premiums – make the most use out of it!
The law also says that it’s for the “entirety of the breastfeeding journey.” This means there is no time limit on when you can file a health insurance claim for lactation support services. No matter whether you are breastfeeding a child at 3 months, 15 months or 4 years, a health insurance plan needs to pay for the lactation support. If your health insurer tells you otherwise, we recommend pushing back because the law is very clear here that there is no time limit.
Your health insurer might have a directory of “in-network” lactation professionals that they contract with to make the claims process much easier. Try to get ahold of this directory and find someone who is an “in-network” provider. Most health insurers will only contract with lactation professionals that have a certain credential: an IBCLC certificate. An IBCLC stands for an International Board Certified Lactation Consultant and they are considered the “gold standard” for lactation training and education. If you work with a lactation professional that doesn’t hold this IBCLC certificate, there is a high likelihood that your health insurer will reject your insurance claim. Make sure to confirm that the lactation professional you wish to work with is an IBCLC, if getting insurance coverage is important to you.
Health insurers, by law, must provide a directory of in-network providers to their members/customers. If your health plan does not provide you with an up-to-date directory of “in-network” lactation providers, then they must allow you to find your own “out-of-network” lactation provider instead. This article will teach you the differences between “in-network” vs. “out-of-network”, if you wish to learn more.
The health insurer can’t try to charge you fees for seeking assistance from an “out-of-network” provider if you are not given an adequate directory of local, “in-network” lactation professionals to choose from.
Many health insurers try to limit their directory to only a few professionals, like Pediatricians, OB/GYNs or lactation providers that are located far away, in hopes of limiting their usage (and saving them money). If this happens, you can request what’s called a “Network Gap Exception” to be allowed to visit an “out-of-network” provider because you can’t find any “in-network” providers that will meet your needs. Each health plan determines, on their own, what is a “reasonable” distance you can travel, sometimes as low as 10 miles or maybe 50 miles away or possibly farther. If there aren’t any “in-network” providers within that pre-set distance, you can request a “Network Gap Exception” to find someone more suitable for you.
Many health insurers will tell you to visit a Pediatrician or OB/GYN if you need lactation support. This is foolish and we recommend pushing back on this request because you likely won’t get good results. Most medical doctors do not have specific training in providing lactation support. They know breastfeeding is important and why, but most received very limited training in medical school. Most doctors do not know how to provide practical guidance & expertise to assist mothers in successfully achieving their lactation goals, such as how to deal with latching difficulties.
Below we will give you additional guidance on how best to deal with health insurers when filing insurance claims. We will also give you some tips / warnings about the process in case you run into any issues and to keep you from getting discouraged. Nobody likes to deal with insurance claims, after all.
Below, we will discuss tips and forewarnings on dealing with health insurers to ensure you get the lactation benefits that are entitled to you under the Affordable Care Act.
Forewarning: many health insurers are using a policy called “reasonable medical management techniques” to try to limit the number of times you can have a consultation with a Lactation Consultant. This “Reasonable Medical Management Techniques” policy is allowed under the law when the guidelines are ambiguous or there are similar alternatives. Since the ACA did not set specific rules surrounding lactation support but gave “vague” guidelines instead, health insurers are setting up their own rules to limit their costs.
Usually, the lower limit for a cap on lactation consultations is set at 6 visits before your health insurer might try to stop paying for consultations. So, if filing claims for up to 6 consultations, there usually isn’t much of an issue. The law is on your side here and if you need the extra support, you should be entitled to it, but you might start getting pushback from your health insurer on these insurance claims, at the 6th consultation mark.