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Insurance Coverage for Lactation Consults

Central to our mission at Lake Norman Breastfeeding Solutions, is to make lactation care affordable for all families. Because of this, we have kept our rates as low a possible to avoid making costs a barrier for families seeking help. Our long term hope has been to secure fair payment from insurance companies for lactation support since this would benefit both families and the lactation specialists whose livelihood depends upon fair payment. However, at this time in North Carolina, insurance providers are not giving private practice lactation consultants the option of joining their networks.

The Affordable Care Act (ACA) Requires Lactation Coverage
The law requires that ACA compliant healthcare plans* cover the cost of breastfeeding support at 100% - meaning you shouldn't have to pay out of pocket as long as you go to someone in-network. The unfortunate loophole is that the ACA did not specify who should provide this breastfeeding support, and most insurance companies have chosen not to add lactation consultants to their networks. Instead they have been asking women to go to hospitals, OBGYNs or pediatricians who receive minimal education in breastfeeding. We hope that eventually the loophole will be closed, requiring that insurance companies bring lactation consultants into their networks and cover our services.

How to Request Reimbursement by Your Insurance
Until lactation consultants are able to become in-network providers, there are few extra steps involved in getting lactation consults reimbursed by insurance, and its not a guarantee.

Call the phone number on the back of your insurance card and ask if they have any in-network lactation consultants in your area - be sure they are checking for lactation consultants, not doctors. If they don't (most don't) then ask them how to submit a claim for gap coverage of a lactation consultant. You may need to remind them that the ACA requires lactation support be covered at 100% as women's preventative services and that since they do not have any lactation consultants in network they must cover the lactation consultant of your choice. The insurance representative will probably want to know the billing codes that will be used. You can ask about any of the codes listed on our example super bill but we recommend asking specifically about coverage for CPT code 99404 and Dx code Z39.1At your lactation consult, be sure to let us know what code(s) the insurance representative recommended so that we can bill appropriately.

Pay for your lactation consult out of pocket, but be sure to keep the superbill (receipt) you are given. After your lactation consult, submit a claim to your insurance company along with the superbill, asking them to cover it at 100% as required by the Affordable Care Act. You may have to appeal if it is declined. When/if the insurance company accepts your claim, they will mail you a check for the cost of the lactation consult. Congratulations on securing your right to free lactation support!

Be sure to let us know how the process worked for you as this helps us to counsel more families on how to secure insurance reimbursement.

*Some families have grandfathered plans that are not Affordable Care Act compliant and may not cover lactation support. But don't give up. You may still be able to get partial reimbursement or have the cost applied to your deductible. Be sure to let us know your plan type so we can code the bill in such as way as to maximize your opportunity for reimbursement. Also note that some Christian health share plans will apply your out-of-pocket cost towards your family's share, reducing your medical costs later in the year.