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Breast Pump Reimbursement

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Did you know that can receive a breast pump and lactation services free-of-charge from your insurance provider? It’s true! As part of the Affordable Care Act, health insurance companies are now required to provide preventative women’s health services without charging a co-pay, co-insurance, or deductible for in-network services for policies beginning on or after August 1, 2012. Preventative women’s services include:

  • Annual well-women visits
  • Screening for gestational diabetes
  • Human papillomavirus (HPV) DNA testing
  • Counseling for sexually transmitted infections
  • Counseling and screening for human immunodeficiency virus (HIV)
  • Contraceptive methods and counseling (certain religious employers may be exempt from covering contraceptive services)
  • Breastfeeding support and breast pumps
  • Domestic violence screening
 
The Breastfeeding support, supplies, and counseling coverage states: “Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment. Breastfeeding is one of the most effective preventive measures mothers can take to protect their health and that of their children. One of the barriers for breastfeeding is the cost of purchasing or renting breast pumps and nursing related supplies.” This new provision will allow for a free breast pump for each birth thereby eliminating the cost barrier to breastfeeding.
 
How to Receive Your Breast Pump
Call your health insurance provider to obtain information on how to receive your breast pump. Be sure to ask for a copy of your benefits and read over the terms carefully. Contact your provider with any questions regarding your coverage.
 
Your insurance company might have restrictions on which pumps are covered and may only cover them at 100% if purchased in-network. Some insurance companies will have you choose a distributor to receive your pump which means you will need to call around to find out the type of pump provided, if the pump is available (some distributors are on back-order for pumps), and when it will be delivered. Other insurance plans have a specific distributor they use and will send you a pump in the mail when available. And others will reimburse you once you have purchased the pump of your choice. The only way to know what your insurance provider will cover is to call and ask.
 
It’s best to call you provider during your pregnancy to make arrangements for obtaining your breast pump once baby arrives. Recently, there has been a shortage on breast pumps and many distributors and breast pump manufacturers are on back order. If you are not able to receive your pump and you need to start pumping, contact your obstetrician/midwife or your baby’s pediatrician and obtain a prescription or doctor’s order to rent a breast pump until your new pump arrives.
 
If you have Medicaid, contact your local WIC (Women, Infants & Children) office to take advantage of the available benefits. Breast pump rentals are provided free-of-charge for WIC clients. Click here to find your local WIC agency and see if you qualify for WIC.
 
If your insurance company does not provide breast pumps free of charge, don’t worry. Most will still cover a breast pump out of medical necessity. Talk to your lactation consultant, obstetrician/midwife, or your baby’s healthcare provider to learn how you can qualify to obtain a pump for medical necessity. A doctor’s order or prescription is needed and must be submitted to your insurance provider to obtain breast pump reimbursement.
 
What is Medical Necessity?
Medically necessary is a term used by insurance companies to describe care that is appropriate
and provided according to generally accepted standards of medical practice. In other words, the
insurance company agrees that this medical treatment is needed for this condition. Learn more about medical necessity and how to talk with your insurance provider to obtain a breast pump and/or lactation services here.
 
Insurance Provider Plan Benefits
Below is a description and links to some of the major insurance providers’ plan benefits regarding breast pump coverage:
  • Anthem Blue Cross Blue Shield: To receive full 100% coverage, the member should receive the breast pump from a contracting Durable Medical Equipment (DME) supplier. One breast pump will be covered each pregnancy.
  • Aetna considers rental of a reusable breast pump medically necessary durable medical equipment (DME) when either of the following criteria is met:
    • For the period of time that a newborn is detained in the hospital after the mother is discharged; breast pump rental is not considered medically necessary once the newborn is discharged; or
    • For babies who have congenital disorders that interfere with feeding, a breast pump is considered medically necessary for up to 12 months of age.
    • For plans beginning on or after August 1, 2012:
      • Aetna considers purchase of a manual or standard electric breast pump medically necessary during pregnancy or at any time following delivery for breastfeeding.
      • Aetna considers purchase of a manual or standard electric breast pump medically necessary for women who plan to breastfeed an adopted infant when the above listed criteria are met.
      • Aetna considers rental of a heavy duty electrical (hospital grade) breast pump medically necessary for the period of time that a newborn is detained in the hospital.
        For women using a breast pump from a prior pregnancy, a new set of breast pump supplies is considered medically necessary with each subsequent pregnancy for initiation or continuation of breastfeeding during pregnancy or following delivery.
      • A replacement manual breast pump is considered medically necessary for each subsequent pregnany, for breastfeeding during pregnancy or following delivery.
      • A replacement standard electrical breast pump is considered medically necessary for subsequent pregnancies, for breastfeeding during pregnancy or following delivery, for members who have not received a standard electric breast pump within the previous three years or if the intial electric breast pump is broken and out of warranty.
      • Aetna considers purchase of heavy duty electrical (hospital grade) breast pumps not medically necessary.
  • Blue Cross and Blue Shield Service Benefit Plan offers a breast pump kit (either an Ameda Manual pump kit or Ameda Double Electric pump kit) for women who are pregnant and/or nursing, limited one per calendar year. The breast pump kit will include a supply of 150 Ameda milk storage bags. You may order Ameda milk storage bags, limited to 150 bags every 90 days, even if you own your own breast pump. Benefits for the breast pump kit and milk storage bags are only available when you order them through CVS Caremark by calling 1-800-262-7890. In addition, breastfeeding education and individual coaching on breastfeeding by a physician, physician assistant, nurse midwife, nurse practitioner/clinical specialist, or registered nurse certified lactation consultant is included.
  • Blue Cross and Blue Shield of Montana is offering a rebate to reimburse a new mother for the purchase of one breast pump per pregnancy. To obtain your rebate follow these simple steps:
    • Check with your group leader to confirm your eligibility for the benefit, or contact a BCBSMT Customer Service Representative at 1.800.447.7828.
    • Purchase the breast pump of your choice (be sure to retain the UPC code of the product).
    • Click here to log-in to the BCBSMT Secure Services website and access the rebate form.
    • Complete all fields of the rebate form and submit the form.
    • Following submittal of the form, you will receive a check in the mail for the cost of the breast pump.
  • Blue Cross and Blue Shield of Nebraska: For breast pumps and supplies to be covered at no cost to you, the pump and/or supplies must be purchased or rented from an in-network durable medical equipment supplier who provides breast feeding supplies. If you purchase a pump or supplies from an out-of-network provider, benefits are subject to your cost share amount not to exceed the maximum allowable amount. In other words, you may be responsible for a large portion of the purchase if you use an out-of-network provider.
  • Blue Cross/Blue Shield Rhode Island: Little Steps® Maternity Program packets are sent to all pregnant participants. This grid includes the general coverage parameters for the plan types listed in the key, but coverage details may vary between contracts and should be verified through the Customer Service Department (BlueCHiP 274-3500, HealthMate 459-5000).
  • CareFirst BlueCross BlueShield: Comprehensive lactation support and counseling by a licensed provider during pregnancy and/or in the postpartum period and in conjunction with each birth. Breast pumps and supplies are provided under the Durable Medical Equipment (DME) benefits of the contract. Coverage is provided for:
    • Manual breast pumps (rental and/or purchase)
    • Electric breast pump (rental)
    • Hospital grade electric breast pump (rental)
    • Replacement supplies (tubing, adapters, shields, etc)
  • Cigna Breast Pumps Medical Coverage Policy: Coverage for breast pumps is subject to the terms, conditions and limitations of the applicable benefit plan’s Preventive benefit or Durable Medical Equipment (DME) benefit with applicable schedule of copayments. Please refer to the applicable benefit plan document to determine benefit availability and the terms, conditions, and limitations of coverage. Under many benefit plans, coverage for DME is limited to the lowest-cost alternative. If coverage is available for breast pumps, the following conditions of coverage apply. Cigna covers a manual or standard electric breast pump as medically necessary for the initiation or continuation of breastfeeding. Cigna covers rental of a heavy duty electrical/hospital grade breast pump as medically necessary
  • HealthPartners: Breast pumps are generally covered under Preventive Benefits per the indications below. Indications that are covered:
    • Purchase of a dual manual (E0602) or a standard, dual electric breast pump (E0603) is covered for all women who choose to breast feed.
    • Purchase of an electric breast pump is limited to once every three years upon subsequent births.
    • Supplies necessary for the use of a breast pump, such as tubing (A4281) and an adapter (A4282) are covered as needed.
    • Rental of a heavy duty, hospital grade electric breast pump (E0604) and purchase of necessary supplies is covered when ordered by a health care provider as medically necessary during the time a mother and infant are separated because the infant remains hospitalized upon the mother’s discharge.
    • Once the baby is discharged, the continued rental of a hospital grade electric pump is not considered medically necessary. The purchase of a standard electric breast pump (E0603) will then be covered as stated above.
  • Neighborhood Health Plan of Rhode Island: Members with questions about their benefits, including breast pump availability, should contact Neighborhood Health Plan at 401-459-6020. Provider requests regarding the availability of breast pumps that have not been addressed by the vendors identified below can be made through DMEnsion, Inc. (Neighborhood’s contracted provider for Durable Medical Equipment) at 1-866-205-2122.
  • Maryland Breastfeeding Resource Guide Insurance Coverage for Breast Pumps: Informative list of breast pump coverage details provided for Maryland’s Medicaid and private insurance companies can be found here.
  • Medica Breast Pump Coverage Policy: Services may or may not be covered by all Medica plans. Please refer to the member's plan document for specific coverage information. Breast pumps are excluded from coverage except in the following limited circumstances:
    • Mother is separated from an infant due to prematurity (less than 37 weeks gestation), illness or hospitalization.
    • Infant has been diagnosed with a condition that affects the infant’s ability to suck or results in poor sucking reflexes. These include cleft palate, Down syndrome, and cerebral palsy.
    • Mother has been diagnosed with and is receiving treatment for mastitis or related infection of the breast or for a lactation disorder.
Coverage is limited to rental of a hospital-grade breast pump or purchase of an electric breast pump. Prior authorization is not required.
  • Tufts Health Plan will cover the purchase of a manual or electric breast pump for pregnant or postpartum Members. The pump must be obtained from a contracting Durable Medical Equipment (DME) provider and the Member must have a physician’s prescription. Learn more about breast pump purchase and rental coverage here.
  • UnitedHealthcare will cover the cost of renting a hospital-grade breast pump or the purchase of a personal, double-electric breast pump at no cost to the member. To rent or purchase breast pumps, members will simply need to contact a network physician, hospital or durable medical equipment (DME) supplier. Members will not be able to purchase supplies, such as breast pumps, at retail and send the receipt for reimbursement.
    • Network double-electric breast pump providers:
      • Edgepark at 1-800-321-0591 or edgepark.com
      • Genadyne at 877-311-9711 or lucinacare.com
    • Network hospital-grade breast pump rental providers:
      • Apria at 1-800-277-4288 or apria.com (not available at all locations)
      • Genadyne at 877-311-9711 or lucinacare.com
  • UnitedHealthcare (UHC) Medicaid- Healthy First Steps Program packets are sent to all pregnant participants. This grid includes the general coverage parameters for Medicaid members, including RIte Care members. Requests for case management can be made through the Healthy First Steps Program at (800) 599-5985 or by Fax at (877) 353-6913. Please allow 2 business days for a response.
Helpful Resources
Learn more about breast pump coverage below:
Have you obtained your breast pump or are currently in the process of obtaining one? If so, come share your experience with other moms here. Your knowledge will be invaluable to a new or expecting mothers.
 
Women's Preventative Sevices - Breast pump, Lactation Service and other Reimbursements
 
 
 

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