Understanding Lactation and Insurance Coverage

This information is for In-network and out-of-network visits, see below for more information
regarding AETNA.

Lactation visits are covered under the Affordable Care Act (ACA) as preventative women’s
health services, one of the few exceptions is a ‘grandfathered’ plan. Many insurance companies
do not communicate their policies to the clients or to the customer service representatives about
lactation coverage which can lead to confusion. Use the guide below to help get your lactation visits covered:

Prepare for your visit:

• Determine if you have a grandfathered plan. If your plan is grandfathered: 1) you would have received notification and 2) You will not have lactation coverage.
• Ask if your plan has any IBCLCs in network. Beware that your insurance may refer you back to your pediatrician or OB for lactation help. I’m sure you have amazing doctors, but they are not a lactation consultant or properly trained for lactation issues.
• If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out-of-net network exemption (or gap exemption). It is helpful to ask for an exception for several visits, it can sometimes take 2 or more visits, especially for complex cases.

Here is the information you need from us to get pre-approval:
Provider Name: Lactation Consultants of Atlanta
NPI# 1144627746 Tax ID # 58-2052409
Address: 2141 Kingston Court SE Suite 103 Marietta, GA 30067.

We typically use diagnosis Code: Z39.1 and procedural codes (CPT codes) 99404 & S9443. The place of service for office- 11, home- 12, and telehealth- 02 with modifier GT.
You should not need pre-approval or proof of medical necessity! Feeding a baby and protecting yours and babies’ health is a medical necessity. It can be useful to get a referral from your pediatrician and/or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.

• If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.
• Keep a written note with the date, time and NAME of the supervisor or agent who you spoke with. Ask them to make a record in your file and to send you confirmation of the conversation and the information you were provided regarding coverage.
• If you receive a GAP exception, include that information when booking your appointment. Payment will be due at the time of your appointment. After your consultation, we will provide you with a superbill. You will need to submit the superbill to your insurance with the GAP exception confirmation to help the reimbursement process.
• If you submit the claim and your visit is denied, we have resources to help you to move forward with the insurance company and will provide you with those details upon request.
• If you do not get the help you need, it is important to ask for a patient advocate to help you manage your case. Mention you will file a complaint with the state insurance commissioner of Georgia and follow through! The more the insurance commissioner hears of insurance negligence, the better chance we have at policy changes.

AETNA’S LACTATION COVERAGE

The TRUTH about the “6 free” lactation visits from Aetna. Aetna’s lactation policy can be complex, not all visits may be completely free. Here’s a breakdown for your reference:

• Aetna’s “6 fully covered” visits are limited: The 6 “covered” visits counted by Aetna are for ONE billing code (S9443). The billing code is for one lactation class, which is ¼ the cost of a lactation visit.

Lactation visits are lengthy and involve multiple patients:
o Each visit typically lasts around 1.5-2 hours and involves both the lactating parent and the baby (or babies in the case of multiples), which means additional codes are needed to represent comprehensive care. For example, a 2-hour visit uses two codes, a preventative code, or a home visit code, and the S9443 for the parent and S9443 for the baby.

Potential reasons you may have reduction in coverage:
o Baby’s coverage varies: The Affordable Care Act (ACA) covers lactation as preventative care for the parent, but coverage for babies varies among insurance policies – some paying in full for the baby, while others trigger deductibles, co-pays, or co-insurance.

Factors that result in additional charges:
o New Aetna coding changes mean it’s more likely that there will be some out-of-pocket expense. Aetna has recently reduced the codes that are approved for lactation billing. o If you have taken online lactation classes or previous lactation visits (even prenatal ones offered by Aeroflow and other companies that help clients, get pumps through insurance) likely billed the S9443 code each time – reducing your remaining number of covered visits.
o HMO plans may require referrals from both the parent’s and baby’s healthcare providers for full coverage.
o Certain plans, especially self-funded plans through the workplace, deny specific codes normally covered by Aetna.
o If you are covered by an employee plan through Wellstar, this is a self-funded plan. we are not a Tier 1 provider, and therefor will not be covered as in-network.

Take action:
o Contact your insurance company to advocate for more coverage. For example, most people are completely unaware that companies like Aeroflow (and others) used up coverage for their prenatal classes. You have the right to ask for those claims to be reversed, especially if you were unaware that they were used!
o Customer service representatives may initially state that the claims were coded incorrectly but be firm and reference the information provided here (and at the top of the page).
o Ask for a health concierge to help you (many polices provide them – ask member services). They help navigate appeals, and work with both you and the provider at the same time.
o If necessary, escalate your call to a supervisor to support your case.
o Report any complaints to the Georgia State Insurance Commissioner: File an insurance complaint

Our claim procedure:
o For each visit, a claim will be submitted – if claims are not covered as they should be – our billing department will dispute if there is a chance that Aetna has made an error. After the dispute process, the billing department will appeal anything over $100 (again, if it is deemed Aetna is in error).
o Any fees that are not covered will be charged to you using your credit card on file, you will receive one email prior to the charge, and you will receive a receipt once charges have been processed. Any bill that is not paid in full due to a credit card denial or error will receive an electronic invoice and will have 30 days to pay before being turned over to collections.
o You can be provided with a good faith estimate before each visit with an email request.
o HSA and FSA are accepted for payment on any charges owed after your claim is processed.

TRICARE:

• We are in-network providers for Tricare East. All Tricare appointments will be attended by two consultants, one to manage the consultation and our certified Tricare provider to assist and oversee the consultations.
• You will receive 6 visits from Tricare East. This includes both prenatal and postnatal visits, 6 visits total.
• For a prenatal visit, the mother must have reached 27 weeks gestation.
• Tricare only covers office consultations.
• For a home visit to occur, you will be responsible for travel related costs that is not covered by insurance, starting rate is $105.00.

National Women’s Law Center:
https://nwlc.org/wp-
content/uploads/2015/08/final_nwlcbreastfeedingtoolkit2014_edit.pdf