The Patient Protection and Affordable Care Act (ACA), beginning August 1, 2012 requires non-grandfathered** health plans to cover preventive services and eliminate cost sharing for such services. This includes the Women’s Preventive Health Services as defined by the Institute of Medicine thus including, “Comprehensive lactation support and counseling, by a trained provider during the pregnancy and/or in the postpartum period and costs for renting breastfeeding equipment in conjunction with each birth.” http://www.hrsa.gov/womensguidelines/ These are the CORE ELEMENTS of the affordable care act. Lactation Consultations MUST be covered.
non-grandfathered** http://www.healthreform.gov/newsroom/keeping_the_health_plan_you_have.html
http://www.healthcare.gov/law/features/rights/grandfathered-plans/
The provision of this cost-effective preventive service will aid insurance companies to achieve the associated health benefits and reduction in costs. Specifically, inclusion of and reimbursement for the services of lactation consultants can improve breastfeeding outcomes and contribute to improved mother and infant health outcomes.
Each health care insurance company is responsible for determining how this coverage will be implemented, so you’ll need to contact your health care insurance provider to learn how they will cover the costs of your lactation support and supplies. Many insurance providers are limiting coverage to in-network providers. This means that while they may be complying with the law in providing full coverage for breastfeeding services and supplies, they may require that those services and supplies be provided by in-network providers who have agreed to provide the services and supplies at the rates that they dictate. In many cases, these rates are 1/3-1/2 of the standard rates normally charged by lactation consultants. Each insurance company and each plan is doing something different to comply. Some will only allow handpumps regardless the situation. And, each insurance company is different from state to state. The results has been major confusion to consumers and professionals and reduced speediness of access of pumps and lactation services.
At this time, I have not enrolled with any insurance carriers as an in-network provider because the rates quoted are not cost-effective for business. However, I am finding that many insurance companies are reimbursing out-of-network claims fully, especially with prior approval. For this reason, it is always worth the effort to inquire and afterwards submit a claim for reimbursement. The services continue to be eligible under Flex Spending accounts.
Here are some facts to support your claim (in addition to the mandate under the PPACA):
- The American Academy of Pediatrics (AAP) recommends that all babies be breastfed for at least one year (PEDIATRICS Vol. 115 No. 2 February 2005, pp. 496-506).
- When breastfeeding difficulties occur, the AAP recommends that mothers and babies be seen by an IBCLC, not a counselor or educator.
- Extensive research over many decades has proven that NOT breastfeeding results in significantly higher healthcare costs as a result of higher rates of maternal and child illness and disease. For this reason, the AAP recommendation for insurance reimbursements for IBCLC services is a cost saving measure to insurance companies.
- The AAP further recommends that third party insurance reimbursements be made for such IBCLC services.
- According to the Surgeon General, “International Board Certified Lactation Consultants (IBCLCs) are the only health care professionals certified in lactation care. They have specific clinical expertise and training in the clinical management of complex problems with lactation .
- IBCLCs adhere to the IBLCE Code of Professional Conduct and practice within the Scope of Practice for IBCLCs.
- IBCLCs are required to keep their knowledge and skills current. They must recertify every 5 years through continuing education or re-examination.
- IBCLCs function and contribute as members of the health care team and make appropriate referrals to other health care professionals and community support resources.
- IBCLCs possess the skills, knowledge and attitudes to provide comprehensive lactation and breastfeeding care and education in routine and special circumstances across the chronological spectrum of pre-conception to early childhood.
- According to the Surgeon General, “International Board Certified Lactation Consultants (IBCLCs) are the only health care professionals certified in lactation care. They have specific clinical expertise and training in the clinical management of complex problems with lactation .
To facilitate your claim, I will provide a “superbill” receipt for your services noting the diagnostic code required by insurance companies after our consultation. BE SURE TO FILL OUT THE TOP PORTION OF THE SUPERBILL.
Your insurance company may ask for my NPI number or my address. All of this information is listed on the superbill and provided above if your Drs office is seeking prior approval. Note that my billing address is different from the address where the service occurs(ed).
Although I am not an insurance expert, always feel free to contact me if there is any way I can help you in your insurance reimbursement process.
Here are websites to learn more about the new law:
healthcare.gov
hrsa.gov/womensguidelines
healthcare.gov/news/factsheets/2011/08
womensprevention08012011a.html