As one of the supporting rules to the women services, and preventative services provision of the Affordable Care Act, The federal law requires new, non-grandfathered insurance plans to provide equipment and services to promote breast-feeding. Such services include; breast pump equipment, and lactation consultant services at no additional cost to the policyholders.
This requirement kicked in for many (not all) plans on January 1, 2014, which is usually the start of new insurance plan years for many employers.
While this new rule has the potential to save many women money while at the same time fueling the breast pump equipment industry it has also been a nightmare for many women to use this benefit.
The nightmare stems from the laws lack of specificity regarding the requirements of health plan providers, and how each health insurance companies hold various rules around this benefit. Some Health plan providers cover purchases of certain types of pumps, others limit the grade and strength of the pump, others require a doctors consent, and most will only cover the pump if its from a vendor that’s been approved and designated by the health insurance provider.
Here is a list of responses from Health plan providers according to the NY Times
An Aetna spokeswoman says its benefit, for plans that cover women’s preventive services with no cost sharing, covers a standard (meaning nonhospital grade) pump within 60 days of birth, every three years, or a manual breast pump within twelve months of birth provided the patient hasn’t already received an electric or a manual pump in the last three years. If you become pregnant before you’re eligible for a new pump, you can still get another set of accessories — typically, tubing and containers — to use with the pump.
A Cigna spokesman said in an e-mail that it developed its coverage based on the federal guidelines. “Cigna covers standard breast pumps as rental up to the purchase price, which is typically reached quickly, therefore the standard breast pump would be purchased for the individual. The breast pumps must be purchased through a national medical equipment company that Cigna contracts with. Hospital-grade pumps are rental only and are subject to precertification.”
Blue Cross Blue Shield of Illinois, according to a summary on its Web site, covers manual pumps only; a footnote explains that “electronic and hospital-grade pumps will not be covered with no cost sharing.”
And United Healthcare says on its Web site that it will cover rental or purchase of electric pumps at no cost to the member who must acquire the pump through an approved hospital or vendor, which will bill United directly for payment.
In most cases new moms will need to do some sort of research before purchasing a pump and not just hope to submit a receipt for reimbursement.
Jackie from South Amboy NJ Wrote: I contacted my insurance company (Qualcare) a few days ago to inquire about breast pump support and they “had no idea” as to what I was talking about. I was asked where did I get this information and they representative kept putting me on hold. To make a long story short, they basically looked up my contract and benefits and told me that breast pump coverage was not included in my benefits
KIC from Texas Wrote: I have United Healthcare and trying to get my breast pump was a complete nightmare. We are only allowed to get the breastpump through hospital or DME (durable medical equipment provider). If the hospital is not set up as a DME then you are out of luck there.
Bijou Minneapolis Writes: Blue Cross Blue Shield of MN only covers a manual pump. Manual pumps are worthless for working moms. Very disappointing.
Through out the United States many new and veteran moms wanting to use this benefit are running into roadblocks, below is a set of recommended steps to consider if you want to use this benefit.
Who to Call to get a free Breast Pump under the Affordable Care Act
- Coverage varies between plans, and providers, using the number on your insurance card contact the customer service department to get more details around your covered benefits.
- If you are not confident with the information provided by the customer service department, asks to speak to the representatives supervisor or contact your employer
- If you are an employee of a larger company, contact your in house benefit administrator, or HR Department to confirm if the service is available.
What to say to get a free Breast Pump under the Affordable Care Act
Phone Script for New/Nursing women
Mom: Good afternoon/morning. I understand under the Affordable Care Act, new health plans must provide coverage for women’s preventive services, such as a well woman visit and birth control, with no co-pay or out of pocket expense. I am trying to confirm my current health insurance plan provide these services. Can you tell me whether my plan is a grandfathered plan under the new health care law?
Scenario 1: If the Plan is Grandfathered:
Mom: Do you know if the plan will still be providing the women’s preventive services without cost sharing?
If the representative says NO:
Grandfathered plans do not have to provide the women’s preventive services, so your plan does not have to provide these services. If you have employer-sponsored insurance, at the next open enrollment you can look at the materials to see if the plan becomes un-grandfathered or if there is another plan option.
If the representative says YES (it will provide coverage):
Mom: Do you have details on how breastfeeding support and supplies will be covered?
- Note: Churches and other houses of worship do not have to provide contraceptive coverage. Additionally, non-profit organizations with a religious objection to providing contraception or sterilization services have an additional year to come into compliance. If your employer or school falls into one of these categories, then your plan still must provide the seven other women’s preventive services.
Scenario 2: If the Plan is Not Grandfathered:
If the representative says that the plan is not grandfathered:
Mom: Can you confirm that my plan provides coverage for the women’s preventive services without cost sharing?
If the representative says NO (the plan does not provide coverage):
Mom: Do you know why my plan does not follow the requirement set forth under the Affordable Care Act for non-grandfathered plans?
Non-profit employers, schools, and universities that have a religious objection to providing contraceptive coverage do not have to provide it immediately.* Self-funded student health plans do not have to comply with the preventive services requirement.
Follow-up question if your non-profit employer, school, or university has a religious objection to providing contraceptive coverage: The temporary delay for employers with a religious objection only applies to contraceptive coverage.
Mom: Can you confirm that I receive coverage for the other women’s preventive health services, such as a well-woman visit?
Follow-up question if the representative indicates that your student health plan is self-funded: Do you know if the school is planning on offering coverage of any of the preventive health services without cost-sharing even though it is not required to?
Here is a link to the Question flow chart
If the representative is unable to answer your questions, asks to speak to their immediate supervisor, or speak to your HR Benefit administrator.