There are many questions about breast pumps, insurance and the Affordable Care Act. Unfortunately, there are no clear answers. Each insurance company is different, as companies grandfathered in under specific regulations are not required to provide one.
Since August of 2012, insurance companies have developed policies to be compliant in providing breast pumps for new mothers. Each company has taken this to mean something a little different. Here are some tips to help you ask the right questions when you talk to your insurance company about your specific benefits.
Use these guidelines to help you decide about a breast pump purchase or rental:
- Each insurance company is different in the type of pump they provide, and you may or may not have a choice in the type or brand of pump you want
- Most companies only pay for a hospital grade pump (rental) if the baby is separated from mom
- Some companies only allow a mother to order a pump after delivery, which means you may not have it at home before you deliver
- Certain companies require you purchase a pump from a specific provider of medical equipment
- Generally, pumps purchased at retail stores are not covered under insurance plans
- If you buy a particular type of pump, your company may not fully reimburse you
- Check to see if there is a deductible to meet or if it has been met
- You may be able to upgrade but your cost may be more and reimbursement less
- Most companies require a prescription for the pump, a diagnosis code, and procedure code in order to file your claim with your insurance carrier. Diagnosis codes and prescriptions can only be provided by your doctor or primary care giver.
- Ask if prior authorization is required and what the steps are
- Insurance companies may provide you with a list of places providing durable medical equipment (DME) but not all of them sell breast pumps. Ask them for only the ones who sell breast pumps
- Pump replacement parts and accessories are not usually a covered benefit
- Outpatient consultations may only be covered by a certified lactation consultant if they practice under the direction of a physician or within the hospital
- Always check with your insurance company about benefits related to breast pumps and lactation consultations once you leave the hospital
Before purchasing a pump, review your policy to know what your benefits are. Then call your insurance company and ask detailed questions about the purchase process. Use the tips above as a guide to forming your questions. The Rex Lactation Station staff can be reached at 919-784-3224. We are happy to answer your questions!
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About the Expert: Robin Deal, BSN, RN, CCE is the Perinatal Services Manager for Lactation Services at Rex and has over 34 years of nursing experience in women’s health.