Who Determines What’s Medically Necessary For Breast Pumps?

Did you know that you might qualify for a breast pump through insurance? That’s right, Mama. Instead of adding a breast pump to your registry or buying one from Amazon, check with your insurance company and get one for free. You might not get your favorite breast pump. Which pump you receive depends on what’s considered to be medically necessary by your insurance company.

What Is Medically Necessary For Breast Pumps?

The Affordable Care Act (ACA)  went into effect in 2010 to revolutionize the healthcare industry, but one of the biggest changes occurred in 2012, when the ACA began requiring health plans to cover breast pumps and supplies! This was and still is a big deal because the use of a breast pump helps mothers be able to maintain their breastfeeding goals.

The ACA actually has breastfeeding covered in two locations. One amends FMLA to require employers to provide reasonable break time to express breast milk. The ACA’s expansion of preventive services.

“Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing moms.”

How long are moms eligible for this coverage?

Breast pump supplies are covered by insurance “Coverage of comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment extends for the duration of breastfeeding. Nonetheless, consistent with PHS Act section 2713 and its implementing regulations, plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive item or service, to the extent not specified in the recommendation or guideline.”

To be specific, they must cover the “cost” of a breast pump. However, health plans only have to cover what is deemed “medically necessary” and the individual payers get to decide that. So what you receive or how much you pay for your pump depends on your insurance coverage.

For example, some plans only cover manual breast pumps as necessary. It’s the bare minimum, but hey it works. It gets the milk out of your breasts. Other companies may cover double electric breast pumps with a certain amount allotted for a reimbursement rate. Also, they may cover a pump for you to keep or a rental pump.

Reimbursement Rate Examples:  

Before April 2018, Anthem Blue Cross Blue Shield paid $169.15 for a double electric breast pump. That reimbursement may cover a Spectra S2Plus, Lansinoh Smartpump, or Medela Pump-in-Style-Advance. All industry standards as quality top of the line breast pumps. After April 1st, Anthem slashed the reimbursement rate to $95. If a mom was one of those 40 million by Anthem, she would have to pay the difference to get one of those breast pumps.

Medically Necessary Breast Pump Helps Moms Express MilkAs breast pump manufacturers raise the bar for quality pumps like the Willow or Elvie hands-free breast pumps or the Medela Sonata with all the bells and whistles, they’re becoming too expensive for coverage rates. Other manufacturers are purposefully designing pumps to be covered by insurance.

Is being able to connect your pump to your phone via Bluetooth or the hands-free ability to express breast milk while multitasking medically necessary? Probably not, but this creates pump inequality as coverage only provides for basic items while some moms get modern, comfortable, advanced options. This potentially leaves low-income moms without the ability to receive what is considered to be a “high quality” breast pump.

Some durable medical equipment (DME) providers (where you will get your pump through insurance) will provide upgrade options. Meaning they will allow you to pay the difference for another breast pump option.

best breast pump

What Questions To Ask Your Insurance Provider

1. What Does Your Doctor Recommend

If you want to discover your breast pump options it’s best to connect with your doctor and insurance provider to see what they will cover based on what your doctor recommends. For example, your doctor will recommend a hospital grade breast pump if you actually need it. Also, some providers require you to receive a prescription from your doctor for a pump before you can get one.  

2. When Can You Get Your Pump

Different insurance providers will allow you to receive your pump at different times. For example, you may have to wait until your six weeks before your due date, your actual due date, or until your baby is born.

3. What Type Of Pump Is Covered is a double electric breast pump medically necessary?

Ask what type of pump will be covered to see if you can get an electric or manual one. Knowing the reimbursement rate will help you shop your options.

4. Ask Where You Can Get Your Pump

Will your insurance carrier reimburse you for a breast pump if you go buy it yourself and submit the receipt or do you need to use a medical equipment supplier?

5. Ask About The Paperwork

See exactly which forms are necessary for you to fill out to receive your breast pump and if you need to fill out a form from your doctor. Then make copies of these forms to keep on file in case you need them later.

6. What About New Breast Pump Supplies

Pump supplies like valves, tubes, milk storage containers need to be replaced on a regular basis to keep your breast pump functioning, but each insurance provider has its own resupply and accessory options! For example, some carriers only cover two storage containers, when you may need six to pump during the workday.

Also, some insurance companies don’t replace breast pump parts until after 90 days because most manufacturers’ warranties last at least 90 days. So if something breaks you’ll have to refer to your breast pump manufacturer’s warranty to get items replaced.

Simplify The Process

Whoa, this is a lot of rules and regulations to follow. You’re busy expecting your new little bundle of joy and don’t have time to make all these phone calls! That’s why you should connect with the best DME to handle all the paperwork for you.

The best suppliers with top notch customer service will match you with a rep who will verify your insurance information, present you with your breast pump options, and submit all of the necessary paperwork to your doctor and insurance provider to make sure your pump gets sent on its way! Sit back and relax while someone else handles all of the red tape.

2019-06-11T15:36:56+00:00June 11th, 2019|Categories: All|Tags: , , , , |Comments Off on Who Determines What’s Medically Necessary For Breast Pumps?