The Affordable Care Act: Breastpumps, Lactation Services and Coverage What is ACA? The Affordable Care Act (ACA) which was signed into law in 2010. There are many parts of the ACA, but one of the most valuable is that ACA requires health plans to cover breastfeeding support and supplies. Many health plans began implementing this coverage on or after August 1, 2012. Does this apply to me? If you have a private insurance carrier or commercial insurer, this law applies to you. Currently this law does not cover Medicaid or WIC. Every Plan is Different: While the ACA is expanding benefits for breastfeeding, changes to coverage will vary among insurance plans. Therefore, your first step is to understand the coverage and benefits available to you through your insurance plan. Most insurance companies offer a toll-free customer service number that you can call with specific questions about your health plan. (This number is typically found on the back of your insurance card.) The insurance plan representative should be able to explain your insurance coverage for any of the products or services that you receive. It is important to know that many insurance plans require that you see an “in-network” or “participating” healthcare provider. Innetwork simply means that the healthcare provider or lactation consultant has made an arrangement with the health plan to provide services to its members. In some cases, going to an out-of-network healthcare provider or lactation consultant may mean that your services may not be covered at all, or that you may have to pay a higher copay than if you saw someone in your insurance plan’s “network.” Questions to Ask your Insurance Carrier: When calling your insurance company about your health insurance benefits and coverage, you may ask the following questions: Pumps My Insurance Provider Cover What type of pump can I get? Do I have brand options? (hospital-grade rental pump, double or single electric personaluse, battery or manual pump, a Medela pump) Do I have to get the “recommended” pump or can I choose to purchase one (aka “out-of-network”) and submit the receipt for reimbursement? o If yes, what amount will I be reimbursed? Is there a dollar limit on coverage for breast pumps? If I have already obtained a breastpump, can I submit a claim for reimbursement? Do I have to get the breastpump (or lactation visits) approved first? Acquiring My Pump When can I get my breastpump? Before giving birth? After the birth of my child(ren)? Where can I get my breastpump? Does it have to be from a designated place (aka “in-network” provider) or can I choose where to get it? Lactation Consultation Is there a limit on the number of visits with a lactation consultant? Where can I receive lactation counseling services? Are there approved in-network providers? Can I get reimbursed if I use a lactation counselor out-of-network? Pump Required for Medical Necessity Do I have a rental pump option? Do I need a prescription for proof of medical necessity?
The Affordable Care Act: Breastpumps, Lactation Services and Coverage (p.2) Does my insurance cover visits with a lactation consultant? Under the ACA, lactation services are covered without co-payment. However, you will need to speak with your individual provider to understand the effective date with your policy and the specifics of how that benefit will be provided.
Again, once your provider has implemented changes required through the ACA, lactation services and breastpumps are provided without co-payments; however, each provider writes their own policy so it is very important to speak with your provider to understand your benefits and coverage.
US Department of Health & Human Services Helpful Sites: www.healthcare.gov www.hrsa.gov/womensguidelines/ www.womenshealth.gov