“Will my insurance cover my visit? Are you in network with my insurance?” are understandably among the first questions many patients ask me.
It is very difficult for IBCLCs to become in network with most insurances, for a number of reasons I won’t go into here! The Affordable Care Act (Obamacare) mandates lactation coverage be offered to patients at no out-of-pocket cost; how well your insurance company complies with that can really vary.
I currently have seen patients get consistent (although of course never guaranteed) reimbursement with the following plans:
- Empire Plan
With these plans, patients pay the out of network fee at the time you schedule a visit with me. I then submit directly to your insurance for you to be reimbursed, no extra steps needed on your part. From there your insurance company should communicate directly with you, including sending any reimbursement check directly to you. Schedule your visit here.
I currently contract with a company that bills the following insurances for my care:
- Blue Cross Blue Shield
- Plans utilizing Provider Networks of America (check the back of your card for the PNOA logo)
Patients with these plans pay no out of pocket costs for care for up to 6 visits. Click here to verify your benefits and schedule an appointment with me.
Unfortunately, Fidelis/Medicaid will not reimburse for lactation care provided outside of a medical office or hospital. Cayuga Medical Center offers outpatient lactation visits on a limited basis and tries to prioritize patients with Medicaid plans; contact the Birthplace at CMC for more information.
Have a different plan from the ones listed above? Please contact me if you have questions about my experiences with other insurance plans.
Requesting a gap authorization from your insurance
Some patients ask whether they should request a “gap authorization” or pre-approval from their insurance to pay for out of network lactation care, given that their insurance company has no local IBCLCs in network. You are welcome to do this, but note that it may take up to a week or more for the authorization to process, and the authorization may not cover the full cost of care. Discuss with your insurance company what their reimbursement rate for out of network care will be, and what the length of the approval process will be, to decide whether you would like to go through this process. Below is some information they may request from me in order for you to apply for the exception:
In the Flow Lactation NPI: 1164936175
Diagnosis code: Z39.1 (care and exam of a lactating mother/person)
Procedure codes: 99404, 99403, and S9443
Please ask if you have further questions. I continue to seek ways to make lactation care more accessible and affordable for all.