By Raechel Conover, Cheapism.com
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.
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.
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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.See what options new parents have with the Affordable Care Act.
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?
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.
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."Take advantage of the Affordable Care Act.
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."
Breast Pump Options. I called Medela, a well-known and highly regarded manufacturer of breast pumps, to learn which machines are available through the ACA. Medela supplies four models: the Personal Double Pump (57038) and Advanced Personal Double Pump, which are not sold at retail; the Pump In Style Advanced (starting at $252); and the Freestyle (starting at $323). The Personal Double Pump (57038), a double electric breast pump with single-phase expression technology, is the model the DME provider had slated for me. The others are double electric breast pumps with the more desirable 2-phase expression technology.
My primary question for Medela was: Why supply single-phase technology when Medela's own testing shows the 2-phase technology is more efficient? "We want moms to get a double electric breast pump," said Claudette Yasell, who manages public relations and clinical writing for Medela. "Offering the single-phase double electric pump is a way we have found to give them that option even if their insurance isn't going to cover as much as the other three options. It's still a better option than a mom returning to work full time and pumping in a break room with a single manual pump." Although the company lacks data on which pump is given out most often under the ACA umbrella, one thing is certain -- demand has increased.
The ACA further stipulates that lactation assistance be provided in the form of a trained professional. In my case, my insurer fully covered the consultant's $180 fee for an hour-long session. Nagin, the private lactation consultant, said about 3 out of 4 of her clients are reimbursed for about 90 percent of her fees by their insurance providers. Still, Madden noted that some carriers only cover basic counseling provided by in-network physicians of unknown lactation experience.
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Getting Breastfeeding Support and Coverage. What can you do if you need breastfeeding support? You have several options. Everyone I spoke with recommends first talking to your insurance provider to learn what is covered. Madden, from the National Breastfeeding Center, also suggested asking about whom you can call on for lactation help. "Can you see an out-of-network lactation consultant? If not, why not? If the insurer is only covering in-network providers, have them refer you to a qualified consultant. If they say they only have physicians, ask them to identify which ones are qualified to deliver these services. If they say they don't know, quote the law about 'trained provider' and let them know that you may file a complaint with the state insurance oversight body (varies from state to state) if they don't find you one."
The next step is to engage your employer if you have insurance through the workplace. Ask your employer about what is covered, Madden urged. "Once an employer begins to look at this, they will see if coverage is adequate or not," she said. "Approximately 60 percent of large companies are now 'self-funded' and have the ability to dictate coverage in some cases and can make sure that their employees are properly covered under the ACA."
If you still can't assemble affordable support under the terms of your insurance plan, you have not exhausted your options. "Of course it depends on how full force a mom is willing to be about breastfeeding," Nagin conceded. "But if she is committed and her heart is there, there's always a way."
- Find a free lactation consultant or support group. Many La Leche League groups are free and can be a tremendous help.
- Learn to hand express.
- If possible, have the childcare provider (oftentimes the spouse) bring the child to nurse at work during a scheduled pumping session.
- Get a hand pump -- far cheaper than an electric pump.
- Buy an electric pump outright -- it's cheaper than the cost of formula for a year.
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Borrowing a breast pump is never recommended because most pumps sold at retail are open systems, which allow some milk to enter the inner chamber that could be transferred to someone else's baby. Rental pumps are much higher grade and are designed with a closed system. There are exceptions, however. Hygeia makes a line of breast pumps called Enjoye that feature a closed system and start at about $200. This product may be the solution if you absolutely must borrow a breast pump or plan to buy one and pass it on to a family member or friend.
In an effort to make the ACA's breastfeeding support process easier to navigate, Medela has added a breastfeeding insurance page to its website. The National Breastfeeding Center and the United States Breastfeeding Committee have jointly created a model payer policy to help insurers meet the requirements of breastfeeding support stipulated by the ACA.
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