Under the ACA, insurance companies must cover a breast pump and supplies at no cost to pregnant members or members who have just given birth and are breastfeeding. The challenge is that the ACA doesn’t say what types of breast pumps insurers should cover, including their price range. As a result, breast pump coverage varies widely depending on what insurance you have.
contact your insurance company
Since there are no standard guidelines, calling your insurance company is the best way to find specific details about your coverage.
“I tell my patients to call their insurance company before the third trimester,” says Lisa Paladino, a Certified Nurse Midwife and International Board Certified Lactation Consultant in private practice in Staten Island, New York.
In paladino’s experience, most insurance companies have a dedicated maternal and child specialist who can explain the process and the coverage you are entitled to. but start by calling the member services phone number on the back of your insurance card.
ask the right questions
Before you make the call, gather your questions. Here’s a list to help you get started, along with what you can expect the representative to say:
- what types of breast pumps are covered? Some insurance companies offer up to nine options, including dual electric, single electric, battery and manual models. At the other end of the spectrum, some insurance companies only offer one or two options.
- Where can I get my pump? Most insurance companies require that you get your pump from an in-network provider. There are usually several options, so ask for their list. In-network providers are often online durable medical equipment (DME) providers, such as Yummy Mummy or AeroFlow breast pumps. “These providers specialize in working with insurance companies,” Paladino says. “They know which pumps your insurance covers, they have all the forms, and they know what documentation you need. and you pay nothing in advance. It can be a very easy process.” Providers within your insurance company’s network may also include retail outlets such as Walmart and Target. these stores also have an online process for ordering your pump. once you know which providers are in-network, choose one and go to their website. Most of these companies (including Walmart and Target) have tools on their home pages that allow you to select your insurance carrier and state. once you’ve entered your information, it will show you all the pumps your insurance covers.
- Do I have the option to upgrade my breast pump? Some insurance companies and dme providers will allow you to upgrade to a more expensive pump if you are willing to pay a portion of the cost. if this is an option, the website will highlight pumps that are considered updates. 100% covered pumps will say $0.00. upgrades will include a dollar amount that is your share of the cost if you want that pump. Whether you have this option varies by insurance company.
- Do I need a prescription? You may need a prescription or prior authorization to get your pump. ask about this policy so you don’t rush to get it from your midwife or obstetrician at the last minute. even if you don’t need a prescription, the dme (or other provider) may need to verify certain information with your doctor before shipping your pump. Again, this process varies by insurance company.
- Does it cover hospital pumps? A hospital grade pump is an electric pump that is more powerful than a personal double electric pump. “Most insurance companies don’t routinely cover these pumps unless there’s a medical necessity, like the baby was born tongue-tied or low birth weight, or the mother has a low milk supply,” he says. paladin. in these cases, your doctor or midwife will need to provide a prescription and a diagnosis code.
- will i have to pay anything for a hospital grade breast pump? These pumps are very expensive, costing as much as $2,000. If you’re eligible, the insurance will cover a rental, not one you keep. You may need to purchase your own collection kit, which includes the tubing, valves, breast shields, and bottles you need to use the pump. you may have to pay a deductible before your coverage kicks in, as well as a copay. your costs are determined by your plan’s dme coverage. The insurance representative you speak with should be able to look up this information while you’re on the phone with them.
consider multiple breast pumps
If your insurance company offers multiple options, you’ll need to decide which type of pump works best for you. here is a brief overview.
- double electric breast pumps: “electric breast pumps are designed to mimic the way you breastfeed a baby, first using quick, short pulls to create a drop, then a longer pull says nicole drury, a certified latte league leader in northampton, massachusetts. “The double electric is the most efficient type of pump, as it allows you to express milk from both breasts at the same time. but some women don’t really like this setup and feel like they’re hooked up to a machine,” she says.
- simple electric breast pumps: you can only pump one breast at a time. once with this style, which may take longer. but some women like to have the option of expressing milk from one breast and letting the baby feed from the other breast at the same time.
- battery-powered breast pumps: these extractors can be ideal when you are on the go. “If she’s on the road and doesn’t have guaranteed access to an outlet, she could pump water in the car if necessary,” Drury says. “this pump may be right for you if portability is more important than speed.”
- hand pump: “some women love this low-tech option,” she says drury. “they are super portable and i know a lot of moms who swear by hand expressing a lot and say they can get really good suction and a long pull.”
how to get your bomb
The time you can get your pump varies. each insurance company has different guidelines as to when your breast pump can be shipped. if you don’t get it while you’re pregnant, you can get it after you give birth. but paladino suggests doing it in the third trimester, if possible. “It’s one less thing to worry about,” she says.
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can my insurance company refuse to cover a free breast pump?
If your insurance company says your coverage doesn’t include a free breast pump, the most likely reason is that your plan is considered an “exempt” plan. these are plans that existed prior to march 2010 (when aca was enacted) and have not changed substantially since then. protected plans are not required to comply with certain provisions of the aca, including coverage of preventive services at no cost.
If you are denied a breast pump and believe your plan is not a protected plan, you have the right to appeal. The appeal process should be clearly stated in your member handbook or on the insurance company’s online website. If you need help, contact your state insurance department or consumer assistance program.