Understanding Lactation and Insurance Coverage

Lactation visits are supposed to be covered as preventative care as defined by both Federal (the Affordable Care Act (ACA) and the State of NJ. Because many insurance companies do not effectively inform clients (and sometimes their own representatives!) about lactation coverage, here are recommendations for you to follow:

  • Before your visit:

    • Call your insurance to ask about coverage. To help with that call:

      • My NPI is 1205245537, My TaxID is 471565055.

      • For out-of-network visits, I typically use diagnosis code Z39.1 and procedure code S9443 for the full value of the visit. If they say they won’t cover S9443 up to my full rate (see FAQ page for those amounts), ask about their coverage for codes 99404 and/or 99204.

    • Ask for a list of in-network IBCLCs. If they can provide no one in your area, ask for an out-of-network exception (sometimes called gap exceptions, NAP, or other names).

    • If you are limited to only a few visits - don’t hesitate to request more coverage. Get a note from your and/or your baby’s doctor. Here are some examples of diagnosis codes they can use - P92.9 (Feeding problem of newborn), Z39.1 (Lactation care, mother), O92.4 (Low supply), O92.13/O92.23 (Mastitis), Q38.1 (Ankyloglossia/tongue-tie)

  • Red-flags to watch out for:

    • If they tell you visits are only covered with an OB or pediatrician - they are wonderful doctors, but they are not lactation/infant feeding specialists.

    • If they ask for pre-approval or proof of medical necessity - feeding a baby and protecting your breast health is a medical necessity!

  • For out-of-network policies I take payment up front (see FAQ page for fees), and provide a superbill for you to submit for reimbursement. For in-network policies I submit the claim and then bill you for any patient responsibility after the claims processed. Scroll down for more info if your visit is not covered correctly (helpful for both in- and out-of-network policies)

In-network Coverage

 
 

  • Aetna tends to limit people to “6 fully covered visits”, but this is not entirely true. The number 6 usually refers to one billing code (S9443 - lactation counseling). Because lactation visits are lengthy (typically 1.5-2 hours) and involve multiple patients (the lactating parent and the baby (babies if multiples)), the lactation code pays only about 1/4 of the fee for most visits (see FAQ page for examples of full visit fees).

  • This means additional codes are needed to represent comprehensive care for and reasonable payment for your lactation consultant. A 2-hour visit is typically coded with 99404 and S9443 for both parent and baby. Some Aetna policies may count each use of the S9443 code as a separate visit, effectively reducing coverage from 6 to 3 visits. The amount not covered goes to patient responsibility - for which I am required to bill you for. Typically this amount is only a portion of the visit (in the form of co-pay, co-insurance, deductible, etc). See below for examples for which patient responsibilities may occur.

  • Baby's coverage varies for all policies:

    • The Affordable Care Act (ACA) covers the lactating parent, but does not specify babies. This means some policies will pay in full for the baby, while others levy deductibles, co-pays, or co-insurance (in my experience anywhere from $5-$100 per visit for the baby).

    • New Aetna coding changes (March 2024) further complicated the situation by taking away a preventative code (Z76.2 - Health Supervision of Infant) from the list recognized as usable by IBCLCs. So, even though the code is clearly preventative in nature, their system no longer accepts it.

    • The State of NJ however specifies that the whole family should be covered for lactation. Use this info (and the info below) to discuss with your insurance.

  • Situations that may reduce coverage and/or trigger patient responsibility for in-network patients:

    • Deductible requirements

    • Previously taken online lactation classes, including the “free” prenatal classes offered by Aeroflow, Nest Collaborate and many other companies. Most people are completely unaware that these companies use your lactation coverage for those classes. You have the right to ask for those claims to be reversed, especially if you were unaware that they were used and/or if you found them unhelpful.

    • Previous lactation visits with another LC (prenatal and/or after the baby arrived) may reduce your coverage with the next LC (note - hospital lactation services rarely cause this issue).

    • If only the parent, and not the baby, has in-network insurance (or vice versa) additional charges will very likely apply. My policy is to bill you the cost of the visit if you were out-of-network (see FAQ page) minus what your in-network policy pays for the visit.

    • HMO plans may require referrals from both the parent's and baby's healthcare providers in order to obtain full coverage. Without the referral co-pays or co-insurances are likely to occur.

    • Certain plans, like the Princeton Student plan or some hospital-based plans, may deny specific codes normally covered by other Aetna plans.

Take action if your claim is not covered (or not covered correctly)

  • Special note for Horizon BCBS - they may deny your claim by saying my TaxID is not valid - this is not accurate and multiple calls from me or other patients have not resulted in them fixing this issue. It’s a great example of too many offices in one company that don’t/can’t seem to communicate with each other. If this happens - be persistent and ask for another rep or a supervisor - request that they dig deeper to find the correct listing.

  • Call your insurance company, and use this info for help:

  • Customer service representatives may state that the claims were coded incorrectly (they were not, most representatives are unfortunately not adequately informed about lactation coverage). Be firm and reference the information provided on this page.

  • Ask for a patient representative or health concierge to help manage your case, and/or escalate your call to a supervisor.

  • If they do not cover your visit(s) correctly, tell them you will file a complaint (and please do!) with the State of NJ office of Banking and Insurance. (Note - if you are not from NJ, many other states have similar offices that you can find online).

Finally - even if your insurance company does the wrong thing and does not reimburse or cover enough visits please know that paying for lactation visits also has tremendous value - including but not limited to: getting help sooner rather than later in achieving your goals and/or reducing pain/anxiety; limiting health issues like mastitis, low-supply, or slow infant weight gain; or avoiding future costs such as formula, oral/dental therapy for the baby, and more.