How to Get Insurance Reimbursement for your Lactation Consultant Visit

BY BOOBER

With all the expenses involved in having a new baby—Strollers! Nursing pillows! Breast pumps!—paying for a lactation consultant can be overwhelming. The last thing you want to be doing is frantically googling “Do lactation consultants take insurance?” when you’re in pain or worried about your baby.

At boober, we want to take the guesswork out of this process, so you can find support when you need it. We’ve compiled our best tips on how to get a visit covered or how to find a professional who will work with you at an affordable rate if your insurance plan won’t cover their services.

What is covered:

Under the Affordable Care Act, many insurance companies are required to cover preventative lactation services without any additional costs or copays. As stated on the Healthcare.gov website, “Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth.”

You can also use this National Women’s Law Center’s Breastfeeding Toolkit to help you determine whether your plan is required to cover services like lactation consultants and where to turn if they do not. This kit also includes great language for how to call your insurance company and demand services.

In-network vs. out-of-network options:

Unfortunately many insurance companies do not have enough (or any) lactation professionals in-network to serve their customers. Time is understandably of the essence when searching for a provider. We know that many parents will give up breastfeeding if they don’t get help quickly.

Don’t despair. According to the NWLC’s Breastfeeding toolkit above, Federal guidance makes clear that “if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.” If you have called your insurance company and they do not have any LCs in-network, the insurance company must cover services from an out-of-network provider without cost-sharing. This means they should reimburse you! This is called an Out-of-Network Exception.

Find a provider nearby—and quickly:

What if your insurance company has a lactation consultant, but they can’t see you for days or the person they send you is a two-hour drive away? Call again and ask for a Geographic Gap Exception. This is a legitimate tool health insurance companies use to compensate for gaps in their network of contracted healthcare providers. You are entitled to ask for your insurer to cover care you get from an out-of-network provider at the in-network rate.

There are other ways to find insurance-covered lactation care. For instance, some pediatrician’s offices (or even your own doctor’s office) may have a lactation consultant on staff who can bill your visit as a preventative service, at no additional cost to you.

Watch out for “grandfathered” plans:

There are some older insurance plans that have managed to skirt around these new regulations, so it’s important to find out whether or not your insurance plan has been “grandfathered” and does not have to cover preventative services. If you purchase insurance through your employer, you can ask your HR department or call your plan directly. If all of this seems confusing—and it is!—call your insurance company and ask what kinds of preventative services they cover.

Get additional support:

If your insurance doesn’t cover lactation consultants, there are still ways to get access to support, such as at your local La Leche League or at a breastfeeding support group. These groups are often lead by lactation consultants.

The most important thing is to get the support you need to keep you and your baby happy and healthy. At boober, not only is there always someone ready to help when you need it, but our Care Connectors can also help you navigate the insurance process to increase your chances of receiving reimbursement. Don’t hesitate to reach out to us to find out how to navigate this complex system. As we always say, #ifithurtsgethelp!