Does Health Insurance Cover (or Reimburse) for Visits with an IBCLC (International Board Certified Lactation Consultant)?
A message from Babies in Common's IBCLC, Jeanette Mesite Frem...
All families deserve access to counseling and clinical care for lactation, breastfeeding, chestfeeding, bottlefeeding and any feeding, really. Period.
The Affordable Care Act of 2010 (law) requires insurance companies to reimburse for "comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment", but some insurance companies/plans are better than others at following the spirit of the law. I cannot guarantee reimbursement to my clients but I will try to help as much as I can.
Your plan SHOULD reimburse you after YOU submit a request for reimbursement (so you pay me directly before or at the consultation with cash, check, credit or HSA/FSA* card). Right now, Harvard Pilgrim, Fallon, Tufts Health Plan, Blue Cross Blue Shield (New England and MA), Aetna, United (possibly with a gap exception referral with my name on it but call United before to request a gap exception), Unicare-GIC and Neighborhood Health are saying they will reimburse you fully or partially, but CONFIRM WITH THEM DIRECTLY, as sometimes they do not. When you call, ask if they will "reimburse', do NOT use the word "cover". If they say yes, you MUST get the name of who said that, write down the date and time of the call AND get a “reference number”. If they say no, demand to speak to a supervisor…get their name, etc…even if they continue to say no (so you can use this info in your appeal).
Other insurances may or may not reimburse, I'm not sure, depends both on your plan AND how many times you appeal a denial. I cannot guarantee anything. I will provide you with a special receipt (CMS 1500 Form) and usually you'll also fill out your insurance company's Claim Form (which asks you for information that is already on the receipt I give you). Call your insurance 6 weeks after our visit if you haven't yet received reimbursement.
I have set up an easy way for you to appeal to your insurance plan if you have a claim that is rejected (see below for sample letters, which are already written for you except for a few fillable fields).
Note if you pay with an HSA/FSA card: if you get reimbursed by your insurance, you must reimburse your HSA/FSA account.
If you saw me or one of my IBCLC colleagues and didn't get reimbursed for the fees you paid for those visits, keep asking...you deserve to get reimbursed and the squeaky wheel gets the oil, right? Insurance companies are betting on you being a tired and overwhelmed parent with a new baby without time to send in your claims and especially not to complain after a denial of a claim. Show them that you are persistent! I know it takes time to put together letters, so I thought I'd do it for you and give you a fillable PDF for each type of letter...so get. this. done! :)
See below for sample letters you can fill out online in a fillable-PDF so you can report your health insurance company for not reimbursing you for lactation care and then send a letter to your health insurance company to appeal them to reimburse you (while including a copy of the letter you sent reporting them...).
Please note that the fillable documents linked below are something I've put together for my clients in Massachusetts, but anyone from any state could use them, so feel free to share with your friends. Also, I did not invent the wheel here, many others have created letter samples as well, which served as inspirations/guides for the letters linked below.
For me to track how many people use the letters, I do ask for the filler's name and email address. Note that the software I use for this process is indeed HIPAA-compliant and I will not release name or email address to anyone, as that is my duty under HIPAA, to keep your information private. You will be able download the completed letters after you fill them in so you can sign them and send them yourself. I will NOT be sending the letter on your behalf nor will I get a copy of the final letter you complete.
By filling out the fillable PDF letters you are NOT engaging with me as your health provider and I am not at all guaranteeing that you will be reimbursed, the letters are merely helpful tools for my clients and others to use in their efforts to get reimbursed for IBCLC-lactation consultant visits.
Sharing your name and email with me does NOT add you to a mailing list, either, but if you would like to join the Babies in Common email list, let me know. Additionally, if you appreciate that I provided this service or other services to you, of course, a positive review on the Babies in Common page on Facebook is appreciated!
SAMPLE LETTER TO YOUR HEALTH INSURANCE COMPANY
For parents who were denied coverage/reimbursement for a private practice lactation consultation.
Information to know as you edit the letter from yourself to your health plan:
- "Grandfathered plans" are not included as part of the Affordable Care Act. These types of plans are health plans that were in place before March 23, 2010, when theAffordable Care Act was signed into law. These plans are allowed to offer the coverage they did before the Affordable Care Act and therefore aren't required to cover/reimburse lactation counseling. If you have had the SAME insurance since before that date, check with your Human Resources department to find out if it is the same or if the plan changed after that date.
- Also see the Women's National Law Center, a fabulous resource, https://nwlc.org/resources/benefits-breastfeeding-moms-understanding-health-coverage-breastfeeding-support-and-supplies/
- For a shortcut of the above link, see this pdf, which also includes a cool flowchart that is helpful: https://nwlc-ciw49tixgw5lbab.stackpathdns.com/wp-content/uploads/2014/10/nwlc_BreastfeedingFactSheet2.pdf
- When you mail this letter to your health insurance, be sure to also enclose the following documents:
- Copy/copies of Receipt/receipts Documenting Out-of-Pocket Costs (the receipt your IBCLC-lactation consultant gave you)
- The letter that you wrote to the Insurance Commissioner of your state, in which you are reporting your insurance carrier to the state for not reimbursing you. A sample letter to the insurance commissioner is also included below.
SAMPLE LETTER TO INSURANCE COMMISSIONER
For parents who were denied coverage for a private practice lactation consultation or breastfeeding equipment/supplies.
Also, be sure to read some important information on the Commissioners website before completing your letter, click here to read that.
As of 11/15/17, the Massachusetts Insurance Commissioner's name is Gary D. Anderson, but please check online to ensure you have the correct name for the current
commissioner. The address is:
Gary D. Anderson
Commissioner, Division of Insurance
Office of Consumer Affairs & Business Regulations
1000 Washington Street, Suite 810
Boston, MA 02118-6200
THANK YOU for advocating for yourself and for others in this journey to get all visits with an International Board Certified Lactation Consultant be covered or reimbursed!
Ultimately, I am hoping that in Massachusetts and all other states (and federally) that IBCLCs will become licensed so that ALL families will have covered (with no out-of-pocket expenses) lactation services with the IBCLC of their choice. Until then, it's YOU and other families who need to scream and shout about this!
While the first intention of you sending letters to your state's Insurance Commissioner and your health insurance company is so you can get reimbursed for the care you
received, those letters and resubmission of claims also scream loudly to the world that coverage/reimbursement for this type of care is needed, wanted and demanded!
Please let me know if these letters have been helpful to you and especially if you think they WORKED to get your claim reimbursed, I want to know!
Please email me at jeanetteibcLc@babiesincommon.com to let me know!
Jeanette Mesite Frem, MHS, IBCLC, RLC
Babies in Common