Lactation Consultant Coverage

Does my insurance cover visits with a lactation consultant?

Under the ACA, lactation services are covered without co-payment.  However, you will need to speak with you individual provider to understand the effective date with your policy and the specifics of how that benefit will be provided.  Please see Coverage Questions for more details. 

Prior to ACA implementation, coverage of services varies from health plan to health plan.  Services that lactation consultants provide are frequently covered under your hospitalization plan while you and your baby are in the hospital.  Lactation consultants may also see you and your baby in the doctor’s office or clinic or possibly in your home.  Your insurance plan may require you to pay a co-payment when you have any services performed in a doctor’s office, clinic or home health setting.  A co-payment, or copay, is a set amount determined by the insurance company that you pay when you receive covered services.  The insurance company pays the healthcare provider the rest of the amount after the provider submits a claim to your insurance company.  The receptionist or billing person at your provider’s office/clinic uses the information on your health insurance or Medicaid card to obtain reimbursement and only charges you the required “co-pay” based on your insurance information.  Often, the healthcare provider’s office puts your insurance information into the computer and electronically processes the claim with your insurance company.

It is important to know that many insurance plans require that you see an “in-network” or “participating” healthcare provider.  In-network simply means that the healthcare provider or lactation consultant has made an arrangement with the health plan to provide services to its members.  In some cases, going to an out-of-network healthcare provider or lactation consultant may mean that your services may not be covered at all, or that you may have to pay a much higher copay than if you saw someone in your insurance plan’s “network.”

If you are unsure whether or not your health plan has a network, ask someone in your employer’s human resources department or call the insurance company.  If there is a network, they often can provide you with a list of in-network healthcare providers and lactation consultants.  Be sure to obtain the most current list available.  Often you can request a booklet of participating providers by calling the customer service phone number on your insurance card.  Some insurance companies also offer this information on their website on the Internet; ask your insurance company for the web address and if they have a provider directory feature available on the website.

Some insurance companies and healthcare providers require that you pay for your breast pump and/or lactation consultant services at the time that you receive them, and then file a claim on your own in order to be reimbursed. 

Again, once your provider has implemented changes required through the ACA, lactation services and breast pumps are provided without co-payments; however, each provider  writes their own policy so it is very important to speak with your provider to understand your benefits and coverage.