Tips for Insurance Reimbursement

MoCo Lactation knows that lactation support is not a luxury, and should be available to everyone. The law agrees!

The Affordable Care Act states, “Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth.” (Some state funded health care plans are grandfathered plans are exempt from this requirement.)

Your insurance company may cover our services. Please use the information below when requesting coverage or reimbursement. We cannot guarantee that these exceptions will be approved, but we hope this helps guide you through the process.

Out of Network Exception

Unfortunately many insurance companies do not have enough (or any) lactation professionals in-network to serve their customers in a timely manner. Federal guidance makes clear that “if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.” If you have called your insurance company and they do not have any LCs in-network, the insurance company must cover services from an out-of-network provider without cost-sharing. This means they should reimburse you. This is called an Out-of-Network Exception.

Geographic Gap Exception

What if your insurance company has a lactation consultant, but they can’t see you for days or the person they send you is a two-hour drive away? Call again and ask for a Geographic Gap Exception. This is a legitimate tool health insurance companies use to compensate for gaps in their network of contracted healthcare providers. You are entitled to ask for your insurer to cover care you get from an out-of-network provider at the in-network rate.

*Information compiled from National Women’s Law Center’s Breastfeeding Toolkit.