Getting Reimbursement
Where to start…
First determine if your plan is grandfathered or not.
If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.
Ask your insurance if they have an in-network IBCLC.
If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out of network exemption (or gap exemption). Make sure to ask for an exemption for several visits since most cases require 2-4 visits and more complex cases can require 6 visits.
Document your conversation.
Write the date, time and NAME of the supervisor or agent who tells you that you are covered. Ask them to note your file and if possible to send you confirmation of the conversation and the information they gave you regarding the coverage under your benefits.
Contact your benefits administrator with your company for help.
If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.
It can be useful to get a referral from your pediatrician and or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.
INFORMATION TO GIVE the INSURANCE AGENT
Provider Name: Jamie Ellen Docherty
NPI # 1639830961
EIN # 85-3951399
Address: 2416 49th St. N St. Petersburg, FL 33710 Phone: 727-346-8850
Diagnosis Code: z39.1
Procedural Codes: 99404 and/or S9443 TELEHEALTH: S9443 Modifier: 33 TELE-HEALTH: GT
Place of Service: 12 HOME TELE-HEALTH: 02
SCRipt to Use
If your pediatrician conceded to giving you the referral then make sure to start the script with this information.
You: I understand that under the Affordable Care Act all plans are required to cover breastfeeding support and supplies without cost-sharing. Can you confirm that my plan follows this Federal guideline?
Insurance Agent: NO, we don’t cover breast pumps or lactation consultants. You: Is my plan grandfathered?
Insurance Agent: NO, your plan is not grandfathered, but we don’t provide this benefit.
You: The healthcare law requires that you provide this benefit. Can I speak with a supervisor to make sure this is the correct information about this policy?
Repeat these questions to the supervisor and insist that under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment [ for the duration of breastfeeding.”
