Affordable Care Act and Breastfeeding
Are You Paying for Breastfeeding Support When You Don't Have To? (Part 1)
A new baby, second time around: I was determined to nurse and knew that I needed breastfeeding support. I began my research and quickly discovered the high cost of breast pumps and lactation consultant fees. Then I learned that the Affordable Care Act (ACA) offers a work-around. In the end, the new health care law helped me obtain breastfeeding support and saved me more than $400. Getting the support I needed and was entitled to, however, proved to be quite a challenge.
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The biggest hurdles faced by would-be nursing moms like me: The law is vague, insurance and medical providers are sometimes uninformed and sometimes pursue the cheapest forms of compliance, and many women lack the knowledge and the energy to wade through all the uncertainties.
My insurance company initially indicated it would cover the full cost of whichever breast pump my doctor prescribed. I called each of the eight durable medical equipment (DME) providers put forward by the insurer. Several didn't know what I was talking about, one wouldn't have the model I needed until weeks after my due date, and another didn't carry breast pumps at all. Finally I struck gold. One DME provider said to call in the prescription after the baby was born.
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After giving birth I met with a knowledgeable lactation consultant in the hospital. She agreed that I needed a breast pump, specifically a double electric, 2-phase model, and obtained the prescription from my doctor. This is when the process started to unravel. The DME provider said it would only give me a single-phase expression pump, not the prescribed 2-phase model that more closely imitates a baby's natural sucking motion. (I subsequently learned that the manufacturer had discontinued the single-phase pump but revived it to fulfill the ACA mandate.)
Despite the consultant's advocacy detailing the reasons I needed the more efficient model, I was discharged from the hospital without a breast pump. She continued to press my case and finally convinced the DME provider to supply the double electric, 2-phase model. As it happened, the local provider actually required authorization from company headquarters to fill the prescription as written.
The representative who met me in the hospital lobby when I returned to pick up the breast pump got me thinking. "I know if I ever have a baby I'll get a lactation consultant on my side," she said. "Your case really opened our eyes and changed how we operate as a company." I was stumped. What was so special about my case? I was only trying to get the breastfeeding support and medical equipment I needed. I consider myself well-informed and with access to helpful resources. What about new mothers who are less knowledgeable, don't have a lactation consultant willing to go to bat for them, or aren't aware that their health insurance plan covers breastfeeding support?
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Here is what I have sorted out about breastfeeding and the ACA. Although the law does not provide an ironclad guarantee of completely free breastfeeding support, with patience and persistence it can significantly reduce your expenses.
ACA and Breastfeeding Support.The ACA contains a little gem of a provision that goes something like this: Payers (insurance providers) must cover at no cost to the patient comprehensive lactation support and counseling by a trained provider during pregnancy and/or after the baby is born, as well as costs associated with renting breastfeeding equipment.
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What does this mean for nursing moms?
As with many laws, this general statement leaves lots of room for interpretation. Breastfeeding professionals may understand it one way while health care insurers may read it another way, which results in lots of coverage inconsistencies. As a new study by the National Breastfeeding Center points out, some insurers cover the entire cost of professional lactation consults along with the most effective equipment while others skate by with minimalist compliance.
"What we have seen is each insurance company interpreting the mandate in its own way," said Susanne Madden, the center's chief operating officer. This welter of policies means that some nursing mothers receive manual pumps, others get hospital-grade rentals, and others are given a single- or 2-phase double electric pump to keep and may or may not be charged a co-pay. "Intentions are well and good, and the ACA is a great thing," said Melissa Kotlen Nagin, IBCLC, RLC, who lectures on lactation topics at Mount Sinai Hospital in New York City and maintains an active private practice, "but people making the laws just don't know enough about breastfeeding."
The upshot, explained Patricia Gollin, RN IBCLC at Columbia St. Mary Hospital in Milwaukee, is that "lactation consultants have had to basically invent the wheel." She said many women enter the hospital without knowing that breastfeeding support is covered through their insurance and their doctors often don't know or understand the provision so they don't bring it up. This leaves lactation consultants to step in and inform pregnant women about their coverage rights.
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The economics of supply and demand also affect the availability of affordable breastfeeding support. In my case, the DME provider had access to both the single- and 2-phase double electric breast pump but preferred to hand out the single-phase model. Why? According to Madden: "Insurers use DME companies because they can contract at low rates when purchases are done on volume. The DME providers then have to find manufacturers willing to sell at discounted rates based on volume. It is rarely a case of, ‘This is a great pump and the research suggests that it allows for X, Y, Z.' Instead it is, ‘How much can I get the pump for and how much can I sell it for?'"
Moreover, Madden said many DME providers were caught short when the mandate rolled out in August 2012. "Many were unaware of it and were not previously supplying breast pumps," she noted. "Then there was a shortage of pumps because manufacturers suddenly had this spike in orders. Many DME providers did not have a clue about what pumps were good, bad, or useless."