Insurance, Fees and Other Frequently Asked Questions (FAQs)

• Why Should I See and IBCLC?

• Insurance and Fees

  • In-network

  • Out-of-Network

  • Insurance Coverage and the Law

• Preparing for Visits

• More Info

  • What is included with visits

  • What issues I help with

  • How I support pumping and bottle feeding (and more)

In-network (Aetna and Amerihealth)

Lactation Solutions of Princeton is in-network with both Aetna and Amerihealth (and most, but not all, of their subsidiaries - please confirm if yours is one that has my services in-network). Most Aetna policies cover up to 6 lactation visits (and even beyond 6 with a co-pay/co-insurance). Most (not all!) Amerihealth policies do not limit the number of covered visits. However it is important to know that the definition of “full” coverage is not always easily interpretable/applicable to your situation.

Here are a few examples that may affect your coverage (note - this is not an exhaustive list, there may be other issues that arise), and in most cases, and estimate can be provided ahead of time.

• If only you, or only your baby, have an in-network policy (in this case, your coverage will be affected - as it is not possible to get full coverage with only one client).

• If you have previously worked with another provider (prenatally or after the baby is born), or taken an online prenatal lactation class (such as the ones given by companies like Aeroflow that help you get your pump through insurance) and they have billed your insurance, it is very likely that they have used up some or all of your benefits. In particular, there are some codes that are only covered for 3-6 visits, so anyone you have seen or any classes you have taken (and been billed for) is considered part of your total covered amount. You can call and ask how many times the code S9443 has been used for your care, and how many you have left. If they have been used up, they will affect your coverage.

• If you have an HMO - a referral may be needed from your healthcare provider is needed prior to service (for you and for your baby) in order to have all of the codes covered properly.

• If you have the Princeton Student plan, they often deny certain codes normally covered by Aetna.

• Some local NJ hospitals and other healthcare systems unfortunately have Aetna plans that do not include lactation - if that is the case for your plan, your visits will be considered out-of-network.

• If insurance mis-appropriates codes, deductibles, co-insurances, co-pays, etc.

• Scale rental, purchased items, and my cancellation policy (see more on this below) are not covered in-network.

For each visit, I will submit the claim and appeal 1 time. After that, any fees that are not covered are subject to billing using your credit card on file. If that occurs, I encourage you to contact your insurance company to fight for more coverage! (see below for more info).

Fees for Out-of-network insurance or other services

Payment is taken prior to, or at the conclusion of, a visit (cash, check or credit card). You will be provided with a detailed receipt to submit to your insurance. Please see below for more information on insurance coverage

Visits are at my office in Princeton - it is very cozy and you will feel at home!

• Initial Lactation Consultation - $280 (parent/baby), $320 (parent/twins). Virtual visits are $40 less.

• Follow-Up Lactation Consultation - $240 (parent/baby), $280 (parent/twins). Virtual visits are $40 less.

• Prenatal Consultation - $140 - virtual visit (unless an in-person visit is desired).

• Home visits are only available on a very limited basis (medical/transportation needs), and only by request. For out-of-network clients, the fee is $40 more for every category (Parent/baby - $320 initial, $280 follow-up; Parent/twins - $360 initial, $320 follow-up). For in-network clients there is a surcharge of $40.

• Military, Tricare, Medicaid, WIC discounts - please inquire

• Scale rental ($25 per week)

• Cancellation fees - Appointments cancelled with less than 24 hours notice are subject to a $50 fee. This fee is not covered by insurance. I will use the credit card on file to cover this fee. And/or an invoice (payable online) will be sent to you.

(all visits include 2 weeks of follow-up - see more info below)

Insurance coverage and the law

Lactation visits are supposed to be covered by law (The Affordable Care Act (ACA)) as preventative care (other than some “grandfathered” policies). You should NOT need pre-approval or proof of medical need (feeding a baby and protecting your breast health is a medical need!). And, the State of NJ has this law requiring health benefits coverage for breastfeeding by IBCLCs.

However - because many insurance companies do not effectively inform clients (or sometimes their own representatives!) about lactation coverage, I highly recommend that you:

• Discuss coverage with your insurance company ahead of time - tell them that lactation is preventative care and that you want to confirm your coverage with your IBCLC. Write down the name of the representative that you spoke with as well as the time and date.

• Some companies limit you to 2 covered visits. You can ask for more coverage - getting a note from your or your babies doctor can help. They can use varying diagnosis codes to help with this - including but not limited to: Dx P92.9 (Feeding problem of newborn, unspecified), Dx Z39.1 (Lactation issues, mother) and Q38.1 (Ankyloglossia (tongue-tie, even if suspected), infant).   

• You can ask your insurance company for a patient representative who can help manage your case - this person is supposed to help guide your coverage.

• In NJ there are very few IBCLCs allowed in-network with any other insurance company other than Aetna or Amerihealth. For any other company - ask if they have any IBCLCs in-network. If they don’t have anyone in-network near you, they are supposed to cover IBCLCs as if we were in-network. This is especially aided by phone calls prior to your first visit, and sometimes they will recommend that you fill out a form for an out-of-network exemptions (sometimes called a gap exception or NAP (or other names, depending on the company))

  • Here is some info to help you with these calls - My NPI is 1205245537 and I will typically write the bill for the lactating parent and use diagnosis codes Z39.1 and O92.70; and procedure code S9443. I can also use procedure codes 99404 or 99204 if those are more acceptable for your insurance company. So please ask about all of those and how much they will pay for any/all of those codes.

• Sometimes insurance companies will say they only cover lactation if it’s with your OB or pediatrician, but please know that exceedingly few physicians also have full lactation knowledge (and they shouldn’t - they specialize in obstetrics or pediatrics!), and NJ law specifies that IBCLCs are the gold standard.

• Hopefully you will be covered the first time you submit your claim, but if you don’t fight for coverage after your visit (this will be easier if you have called and documented coverage prior to the visit). Here are resources to help:

  • Many people are denied the first time, but then covered if they make one phone call and explain that lactation is preventative care (and cite the laws, etc), they will then says “oops” and cover the visit.

  • Tell them that you will file a complaint (and please do!) with the State of NJ office of Banking and Insurance if your insurance company denies coverage or makes you wait for pre-approval.

    • Note - if you are not from NJ, many other states have similar offices, so look those up!

  • The National Women's Law Center offers scripts for speaking with your insurance company - "New Benefits for Breastfeeding Moms: Facts and Tools to Understand Your Coverage under the Health Care Law"

  • Here are a few other pages with excellent overviews of insurance coverage - The Lactation Place, Lucky Baby Lactation, and Rachel O’Brien (Rachel also has two more articles - one, two). Much of the info is complementary to what I have written here, but worth checking out in case they have added new/more helpful info.

And - even if your insurance company does the wrong thing and does not reimburse, or if you just decide it’s too much effort, or if you want more visits than your insurance will cover - please know that lactation visits have tremendous value even if you pay for them! Your visit(s) includes help with latch, position, pumping, bottle feeding, supply issues, oral/motor assessment, and more - potentially saving the costs of formula, future oral therapies, dental issues, etc.

Preparing for your visit

The best way to prepare for all visits is to fill out forms (electronic only, no printing needed!), and for your baby to be not too “hangry” or too full when the visit starts. In addition, here is more info:

office visits

My office is very cozy - you will feel at home!

• Updated Covid/illness policy (April 2023) - we ask that you monitor your health and reschedule if you are feeling unwell (we will do the same). We are no longer requiring families to wear masks, but for now we will continue to do so - to protect the new baby from communicable illnesses. We also run a HEPA filter during visits.

• I have pillows, blankets, flanges, and many other helpful items. But sometimes having your own stuff can be helpful too, so please bring anything that you would like to have for the visit - this includes nipple shields, pumped milk, formula, bottles, your pump and flanges, your “Haaka”, your favorite pillows, or anything you may use for lactation and infant feeding.

Virtual visits

• Have a computer and/or phone for video/audio at the same time (some people use a computer and a phone - one for discussion and one for getting close-ups, better camera angles, etc).

• If available, a support person is very helpful for baby care, better camera angles, etc.

• Set up a comfortable area for you and your baby with good lighting (a flashlight sometimes helps)

• Have on-hand any items you use for nursing, bottle feeding, pumping, etc

home visits

Home visits are for medical/transportation issues only, and are very limited in availability. When available, I can travel up to a 45 min radius from the Princeton area (Mercer, Middlesex, Somerset, Monmouth, Burlington Counties, and parts of PA - see a full list of towns here). Home visits are billed at a higher price (see above).

Please do not spend any time cleaning your home before the visit, I totally understand how hard it is to take care of everything when you have a new baby (or really anytime - for example, my house is messy and my kids are older now!). Masks and other precautions for Covid safety are in effect for me and anyone in your home.

videos You CAn send Ahead of (or after) visits (optional):

• Close up of latch, how a baby drinks from bottle, how your flanges fit for pumping, or anything else you’d like me to see

• The most secure methods to send videos are by email (leslie@lactationsolutionsofprinceton.com), or save them to a Google Drive or DropBox and share with my secure email. You can also text them to me, but this is a non-secure method to be used only if you prefer.

​Can I contact you with follow up questions after a visit?

Definitely!  Solving lactation issues is a dynamic situation - making follow-up critical. Every visit includes 2 weeks of text, email or phone to work on the care plan relating to your visit. And, follow-up visits are helpful for furthering the plan and checking on progress in-person.

Will you work with me if I use bottles or supplementary formula?

Where can I find More resources for Lactation and infant feeding support?

Check my extensive Resource pages (blog) for a ton of information - Latch, position, bottle feeding, pumping, podcasts, and so much more!