It’s a common question for new moms. As of last year the answer is YES! With the passing of the Affordable Care Act (ACA), the law now mandates that breast pumps be covered under the plan at no out-of-pocket expense to the new mother, with some exceptions which are explained below.
Although ACA requires insurance companies to provide pumps, the style and type of pump covered is not specifically set. There are three main styles of breast pumps: manual, electric, and hospital grade. From my experience, the majority of plans are covering a double electric breast pump.
Common Requirements and Limits:
- Most insurance companies require you to purchase your pump through an in-network Durable Medical Equipment (DME) provider.
- Most insurance plans will limit what they pay to a specified amount. Common retail models like a Medela Pump in Style often fall outside the maximum allowable cost. The main reason for this is because most retail models come with extra accessories that many insurance companies consider a convenience item: a bag, extra bottles and ice packs, cleaning supplies, and AC (car) adaptors, etc. For this reason most manufactures of breast pumps have moved to special “insurance model” breast pumps which only include the basic items required for pumping. You can always purchase the “convenience” items separately.
Every plan is a little different so there are a few good questions that you want to call and ask your insurance company to know what your benefit is. It is also helpful to speak their language, so below is a list of questions you can ask.
Is my plan ACA compliant?
- Most insurance plans now are ACA compliant; however, not all. How and why is rather complex, but some insurance plans are “grandfathered” and therefore not subject to ACA. If your plan is “grandfathered” it can be excluded or subject to deductible and out of pocket.
What type of pump is covered?
- As mentioned above there are three main categories of pumps: Manual (E0602), Electric (E0603), and Hospital Grade (E0604). Each is going to have its own set of rules allowable, and billing code called a HCPCS, which are given in parentheses. If you just call your insurance company and ask about a breast pump, they could be giving you rules on a manual (E0602) and you are thinking it’s an electric (E0603). Also please note that an E0603 is called an electric breast pump. The insurance companies do not distinguish between a single and double. When you are talking to your DME provider, you want to make sure they are providing a double electric pump.
How much will they cover?
- For each of the billing codes, the DME supplier and insurance company have a contracted amount which is known as an “allowable.” Allowables vary based on your specific plan, but I’ve found that most private insurance companies have an allowable of about $150.
- One common misunderstanding is that when you call your insurance company, they will likely say something like: “The breast pump is covered under the Women’s Preventive Care Benefit, and payment is considered at 100% no copay, coinsurance, or deductible apply. There is no maximum to this benefit.“ What they are saying is that there is no maximum to what the insurance will pay under the Women’s Preventive Health Benefit, which includes many different benefits – breastfeeding is just one. However the insurance company will still limit payment to the contracted amount for the breast pump. The full list of ACA mandated women’s preventive health benefits can be seen by Clicking Here.
Can I pay the difference for the pump I want?
- The quick and easy answer is no. In order to be an in-network provider, we as a DME company sign a contract with the insurance company saying that we agree to accept the allowed amount for each billing code, and write off any remaining balance. However, we are given the discretion to decide which items we are willing to bill to insurance and which we are not. There are many retail pumps that cost $300-$500, and these pumps would have the same billing codes that cost $150. Theoretically, we could bill the $500 pump, but we would still only get paid the $150, which would be far less then our cost on the pump. Clearly no DME company could afford to do this and stay in business.
Does the pump require any documentation?
- Often a prescription is required just for the DME company to establish you are, in fact, pregnant.
- If you want a hospital grade pump, there must also be a medical reason why it’s needed. Common examples are things like inverted nipples, premature birth, or multiples birth. Hospital grade pumps typically are provided as a rental, with a maximum benefit of 12 months per pregnancy.
Do I need to go to an in network supplier?
- To get your maximum benefit, most insurance companies will require you to use an in-network provider. They should be able to give you names and numbers of in-network providers in your area.
When can I order?
- Most policies do not require any specific time frame for advanced orders and will allow you to receive your pump at any point during your pregnancy. However, I have seen some policies that require you to wait until 30 days before your due date, and others will not provide a pump before the actual birth.
Can I get multiple breast pumps?
- Many plans will allow you to have two pumps if you are planning on going back to work.
This article was provided by Stephen Sear with Mark Drug Medical Supply. Mark Drug is a Blue Cross Blue Shield PPO preferred provider and can provide you with your breast pump. They stock a variety of different pumps, including the Medela Pump In Style Starter Kit You can visit their site: http://www.markdrugmedicalsupply.com/breastpump.htm. Phone # 847-537-8500 Fax # 847-537-8500 Email [email protected]