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Reimbursement Guide
Could
my breast pump be covered by my insurance?
Coverage for breastfeeding-related expenses will vary widely among different
healthcare insurance plans. In order for you and/or your lactation consultants
to be reimbursed for the services and supplies provided, it is important that
you understand the coverage and benefits of your health plan.
Your insurance company (or your employer’s benefits department) can provide
you with a policy handbook detailing the benefits of your plan. If you have any
questions regarding your coverage after reviewing the policy handbook, you
should contact your health insurance plan’s member services department. 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.
When calling your insurance company about your health insurance benefits and
coverage, you may want to ask these questions:
 | Does
my insurance plan cover this breast pump (indicate type: hospital rental,
purchased electric, battery or manual)?
| Does
my insurance cover services provided by a lactation consultant?
| Are
there any restrictions?
| Do I
have to get the pump (or visits) approved first?
| Are
breast pumps covered only for certain medical reasons? If so, what are they?
| Is
my lactation consultant/doctor’s office in the network?
| What
will I need to pay?
| Do I
need to meet a deductible first?
|
| | | | | | |
(A deductible
is the amount of money that you could have to pay before your insurance pays for
or reimburses you for any medical care or prescriptions. Sometimes there are
different deductibles for your family members, depending upon who is covered. An
individual deductible would need to be paid before that person gets
reimbursed or has their medical care paid for by the insurance company.
If the
whole family is covered under one family member’s insurance, then a family
deductible is the amount of money that the family would have to pay first
before the health insurance company would pay or reimburse for medical care or
supplies).
| Is
there a copay for the breast pump that I need or for the visits with the
lactation consultant?
| Is
there a dollar limit on coverage for breast pumps? Is there a limit on the
number of visits with a lactation consultant?
|
|
Sometimes
the insurance company has set a limit on the amount of money that they will pay
to cover your medical expenses. For example, you may have coverage for a breast
pump, regardless of type, up to $100. Another example would be if your health
plan covers only a specified number of visits to a lactation consultant.
This is called a benefit cap or benefit limitation or maximum benefit.
Benefit caps or limits can be for different time periods as well: annual or
lifetime.
An annual benefit cap or limitation is for one year. It is important to
ask your insurance company if you have an annual benefit cap and if so, what
year do they use? Do they go by the calendar year (January to December)
or do they use a fiscal year or plan year (for example, from when your
policy became effective—i.e., August 1 to July 31).
A lifetime maximum benefit is the highest amount of money that your
insurance will pay to cover you for healthcare expenses. For example, you may
have a $1million lifetime maximum benefit. If your healthcare costs go over
$1million, then you will not be reimbursed by that insurance plan for any
portion of your medical expenses that exceed the $1 million limit.
If your plan covers the medical treatment you need, most plans will require that
the treatment be considered “medically necessary” for the patient’s health
condition.
Medically necessary is a term used by insurance companies to describe
care that is appropriate and provided according to generally accepted standards
of medical practice. In other words, the insurance company agrees that this
medical treatment is needed for this condition. For example, if your doctor has
indicated that your baby needs breastmilk (benefits of breastmilk, formula
allergy) or if your baby has some other special need that requires you to pump
your breastmilk, your insurance company would consider this as a “medically
necessary” reason. Some health plans will reimburse for a breastpump (and
related supplies and services) only if there is a “medical reason.”
One general medical reason is that the American Academy of Pediatrics, a highly
respected medical organization, supports the medical benefits of breastfeeding.
The AAP’s Work Group on Breastfeeding issued a position statement that asserts
“human milk is the preferred feeding for all infants, including premature and
sick newborns, with rare exceptions. When direct breastfeeding is not possible,
expressed human milk, fortified when necessary for the premature infant, should
be provided. Exclusive breastfeeding is ideal nutrition and sufficient to
support optimal growth and development for approximately the first 6 months
after birth. It is recommended that breastfeeding continue for at least 12
months, and thereafter, for as long as mutually desired.”
Furthermore, the Surgeon General’s “Blue Print for Action” also recommends
that infants be exclusively breastfed during the first four to six months of
life, preferably for a full six months. Ideally, breastfeeding should continue
through the first year of life.
Some other examples of the medical need for breastfeeding include:
| Baby
cannot suck well due to respiratory disease or other physical impairments
| Baby is
allergic to formula
| Baby is
chronically ill
| Mother’s
antibodies in breastmilk considered medically necessary
| Multiple
births
| Prematurity
| Physical
separation of mother and baby
|
| | | | | |
Many new
mothers work outside the home. This presents a medical need for your baby as
well. Antibodies in your breastmilk can be considered medically necessary to
your baby. Because of your need to return to the workforce, you and your baby
have a medical need for a breast pump. Your employer may support your need to
breastfeed in several ways In fact, many employers support breastfeeding
employees in the workplace by providing private areas or lactation rooms where
pumping can occur during work breaks. Your employer can also help advocate with
your insurance company.
If you are having difficulty with your insurance company in getting your
breastfeeding-related supplies and services covered, you should tell your
employer. Speak with one of your employee benefits representatives. Emphasize
that being able to pump breastmilk will allow you to take less time off because
your baby is healthier and/or you may have been able to return to work more
quickly after the birth of your baby. Inform your employer of the need to expand
health insurance benefits for breast pumps, supplies and services. If many
breastfeeding families approach their employers, they have a much louder voice.
Even one voice is better than saying nothing at all. In fact, employers may
choose a different insurance company/plan if their employees express
dissatisfaction with the current plan choices. Furthermore, insurance companies
may not be aware of how important this benefit is to their customers. By raising
their awareness, we all may have more thorough insurance coverage in the long
run. You can make a difference.
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