Did you know that most health plans are required to cover lactation services? Read on and find out how you can get your lactation consultant paid for.
How to find an in-network lactation consultant in the NYC Metro Area
If you have Aetna insurance, you’re in luck—there are many NYLCA IBCLC members who are in-network with Aetna. That means they can bill Aetna directly for lactation services and you’re not supposed to pay any cost-sharing for your claims. That means no deductible, no co-insurance, and no copay. Because lactation visits tend to go long, your lactation consultant will probably also submit a claim for your baby and that may go to your deductible. But never fear, the cost-sharing for your baby tend to be quite low. Your lactation needs to make sure that they can be compensated for the time they’re going to spend with you.
Other insurance companies have a handful of in-network providers, and you can see if your insurance has anyone in-network here.
Always call your insurance to verify your benefits, because there are some plans that have limitations on lactation coverage even if you see an in-network person. Aetna happens to have a few of these plans. It’s your responsibility to verify your own benefits.
What if I can’t get an in-network lactation consultant?
If your insurance doesn’t have anyone in-network, or if there are no in-network IBCLCs close by or available soon enough, you will be petitioning your insurance to reimburse you for your out-of-pocket expenses.
The Affordable Care Act says:
Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth.
If your health insurance plan is grandfathered (established prior to the ACA), then they are not required to cover lactation. All plans created after the ACA are required to cover.
How to apply for out-of-network reimbursement for lactation services
Your lactation consultant will give you a superbill, which is a specially formatted invoice with codes that your insurance company will recognize as lactation-specific. You will send this to your insurance company and you may need to submit it multiple times before you get reimbursed. If they try to reimburse only part of the amount, or if they tell you that they don’t have to reimburse you, keep trying.
You may increase your chances that this process will go smoothly if you call your insurance company and request preauthorization for a lactation consultant. They may ask you which procedure codes your lactation consultant will use. You can ask about S9443 (lactation class, 1 unit) and 99404 (preventive counseling, 1 hour). Many insurance companies will want one of these two codes and may prefer that the entire fee be put on one of these codes. The diagnosis code for lactation is Z39.1 (“encounter for care and exam of lactating mother”).
The National Women’s Law Center has a great Toolkit that walks you through how to talk to your insurance company about reimbursement.
Additional resources on insurance coverage for lactation services
If you want to learn more, these articles have great information:
Lactation Consultants And The Affordable Care Act (for professionals)