Lactation Support 100% Fully-Covered by Health Insurance thanks to Affordable Care Act (ACA)

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.

Health Insurance Plans

If you have a health insurance plan through:

  • Your employer (also known as commercial insurance) OR
  • Are enrolled in TRICARE (civilian healthcare for the US military) OR
  • Are enrolled in a “Medicaid Expansion” plan

    Then you are also entitled to free lactation support services for the entirety of your breastfeeding journey. Those 3 categories represent the lives of over 75% of the US population (~245 million lives).

You might be asking, “What do you mean free lactation support for the entirety of your breastfeeding

Women’s Preventative Health Services within ACA

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:

  • a Co-pay OR
  • Co-insurance OR
  • Fees against an unmet deductible on your health plan

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!

Entire Breastfeeding Journey

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.

International Board Certified Lactation Consultants (IBCLCs)

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.

In-Network vs. Out-Of-Network

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.

Network Gap Exception

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.

Pediatricians and OB/GYNs aren’t Lactation Professionals

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.

How Insurance Typically Works for Lactation Support

“In-Network” Provider

  • If you have found a lactation professional (usually with an IBCLC certification) that is considered “in-network” with your particular insurance plan, you can usually have the lactation professional file a reimbursement claim on your behalf, at the end of your lactation consultation.
      – This means that you would not pay any money out-of-pocket and the IBCLC will handle all of the paperwork for you with your health insurer. This is why working with an “in-network” provider is much easier, logistically.  

“Out-Of-Network” Provider

  • If the lactation professional (typically an IBCLC) is “out-of-network” of your health insurance plan, then you will likely owe the lactation professional their entire fee, in full, in advance of your lactation consult. Each professional sets their own fees, so this amount will vary widely.
      – After the consultation, the lactation professional will fill out a “Superbill” and give it to you. Then, you will send that Superbill to your health insurance plan to get reimbursed for the fee you paid to the lactation professional. If all goes well, the health insurer will reimburse you for the fees you paid. But, more often than not, the health insurer will try to deny your claim (in full or partially), for numerous potential reasons, in hopes of saving money and pushing the healthcare costs onto you.

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.

Reasonable Medical Management Techniques

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.

How to Best Navigate the Health Insurance Process