Over 17,000 individuals have connected to Breastfeed Chicago through our highly active Facebook group. It was through this group, as far back as 2012, that we first started hearing about problems with the way insurance companies were reimbursing for the comprehensive breastfeeding support, supplies and counseling that were part of the ACA’s expansion of Women’s Preventative Services. We continue to hear about those issues 3 years later and the complaints from IL mothers were echoed at the national level in a recent report from the National Women’s Law Center which documented violations to the ACA.
What is happening here? Why aren’t moms getting the preventative care they are entitled to?
This is a completely new benefit, applying only to non-grandfathered health care plans, that involves providers and equipment not previously included in the healthcare setting. Because of this, guidance from state and federal agencies is needed to implement the requirements uniformly and comprehensively.(1)
To request this guidance, Breastfeed Chicago, using a letter template provided to us from the National Women’s Law Center (NWLC) notified the Illinois Department of Insurance (IDOI) in June 2015 that mothers were experiencing problems. We asked IDOI to meet with us and we requested that IDOI issue a bulletin that clarified the requirements of the ACA(2). You can read the letter we sent here, and the response we received from IDOI here.
We consider the response we received from IDOI unacceptable.
The response does nothing to address the fact that many insurers (maybe yours!) have benefit summaries and reimbursement policies that are in direct violation of the law.
It puts the onus for enforcement with the law onto a vulnerable population – postpartum women. When a mother is struggling with breastfeeding challenges, she has a small window of time to make breastfeeding work. She is not in a place to become an expert in her benefit summary, the provisions of the ACA, or to wait on the State of IL’s complaint process.
The response also impacts families disproportionately because not everyone has the resources to pay up-front and out-of-pocket for services or supplies when they are most needed and then argue with their insurance companies or file complaints about proper reimbursement after-the-fact. This contributes to healthcare disparities.
And lastly, we have identified that many mothers have a fear of speaking out on this issue. Although we know that filing a complaint with the Department of Insurance has no bearing on the coverage a woman carries and that a woman can not be terminated from her insurance or hurt from filing a complaint, we have spoken to many, many women who are afraid to even file for fear of loosing coverage or causing an issue with their employer or their spouse’s employer. Although this fear is unfounded, it makes change difficult because it makes it difficult for IDOI to address the issue when they are not even receiving the necessary complaints.
So, what are we going to do about it?
We are asking IL residents (not just mothers!) to sign on to our petition that urges IDOI to issue the requested bulletin. Over 1,000 individuals have already signed on! Specifically, we are asking IDOI to:
- Require insurance carriers to establish a sufficient network of lactation service providers that can provide comprehensive breastfeeding support so women can obtain timely in-network lactation services at no cost-sharing, within a reasonable distance;(3)
- Clarify that until an insurance carrier establishes a sufficient network of providers of comprehensive lactation support and counseling, women must be able to obtain this service out-of-network, as required by law;
- Clarify that lactation services, as a part of preventative services for women, must be covered at no cost-sharing;
- Clarify that reimbursements are in conjunction with each birth and for the duration of breastfeeding; and
- Provide guidance to indicate coverage limited to a manual pump is insufficient and that there are instances when the rental of an additional hospital-grade pump may be medically indicated, as determined by a health care professional.
We (members of the Breastfeed Chicago Board of Directors) will be delivering the petition not only to IDOI, but we will be using it to demonstrate need for guidance and enforcement as we continue to meet with local legislators and ask that this issue gets attention. NWLC is a wonderful ally for our organization, helping us to speak out at the federal level about our member’s experiences as well.
What if I want to understand more about what my insurance plan is supposed to be covering?
Please take the time to watch National Women’s Law Center’s webinar on violations to the ACA’s breastfeeding requirements, which can help you learn about what your coverage is supposed to be. If you identify an instance when when you feel your benefit summary or claim reimbursement is in violation of the what the law says, for now, please file a complaint with the IL Department of Insurance so that the violation can be individually investigated and recorded. (4) Your insurance company can not take action against you for filing a complaint!
Have an idea to help us advocate for this issue?
1 Non-grandfathered plans are those that are new marketplace plans. These might be plans that your employer sponsors or ones that you individually purchase. If your plan is a Medicaid plan, traditional Medicaid is not considered eligible. However, if you have a new, marketplace Medicaid plan, your plan should be eligible. If you have questions about your individual plan’s status, NWLC is a great resource to help you learn more. First, try using this flowchart. If that is not helpful, contact the NWLC’s CoverHer Hotline at: 866-745-5487 or [email protected]
2 What does federal law actually say?
- Insurers must establish a “network that is sufficient in number and types of providers … to assure that all services will be accessible without unreasonable delay” – see eCFR §156.230
- Until a sufficient network is established, out-of-network claims must be covered free of costsharing. – see DOL FAQ Part XII, Question 3.
- Women’s preventative services are covered at no costsharing, and the requirement is “comprehensive lactation support and counseling” – see HRSA’s Women’s Preventative Services Guidelines.
- The law states that support and supplies are eligible “in conjunction with each birth”- see HRSA’s Women’s Preventative Services Guidelines.
- Eligibility is for “the duration of breastfeeding” – see DOL’s FAQ Part XII, Question 20
3 We are not the only ones who feel that most HCPs can not provide comprehensive breastfeeding support or counseling. The US Surgeon General has stated that clinicians (OBs, pediatricians, primary care physicians, nurses) “report feeling that they have insufficient knowledge about breastfeeding and that they have low levels of confidence and clinical competence in this area.” It is our stance that these providers are not eligible to be counted as providers of comprehensive lactation support and counseling (unless, of course, they have sought additional credentials in lactation). – see Barriers to Breastfeeding in the United States from the US Surgeon General’s 2011 Call to Action to Support Breastfeeding.
4 If your plan is a self-insured healthcare plan, as is common with individuals that get their health insurance from unions or trade organizations (teachers, police, carpenters, etc…), your point of contact for a complaint is: the US Department of Labor (DOL) http://www.dol.gov/ebsa/aboutebsa/main.html; DOL’s Employee Benefits Security Administration toll free number at 1-866-444-3272. Link to submit a complaint: https://www.askebsa.dol.gov/WebIntake/Home.aspx.