Reimbursement Guide

(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).

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:

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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