I accept many insurance plans, making lactation support often available with no out of pocket cost to you!
The ACA (Affordable Care Act) mandates that lactation support be covered as preventative care. Unfortunately, many insurance carriers make this benefit difficult to use by limiting IBCLC insurance network participation. I have done my best to ensure my services are covered by as many insurance companies as possible.
Aetna PPO:
I am in network for lactation with many Aetna PPO, EPO, OA, POS, and other plans (unfortunately not HMO). Aetna typically covers 6 lactation related visits with no cost sharing. For a full list of in-network plans, please click here. Please submit your information directly to me (via text or e-mail) for eligibility confirmation.
Cigna
I am able to accept Cigna by partnering with Wildflower Health for lactation. Please submit your information here to verify benefits.
United Healthcare
I am in network with many UHC plans (including some HMO, EPO, and POS plans) for lactation.
Please submit your information directly to me (via text or e-mail) for eligibility confirmation.
Tricare:
I am in network for lactation. No referral necessary for those on Prime or Select!
Please submit your information directly to me (via text or e-mail) for eligibility confirmation.
Medi-Cal:
I am an approved Medi-Cal doula (birth and postpartum). I can also provide advanced lactation support and education within the scope of a postpartum doula. I am waiting on contracts with Cal Optima and Kaiser. For those with Cal Optima, Blue Shield Promise (or another Medi-Cal plan), please contact me and we can get a single case letter of agreement (LOA) prior to meeting. This allows my services (as a non contracted provider) to be covered as if I were in-network.
Please reach out for any questions!
Other PPO Insurance Plans:
I have attempted to become an in network provider with Anthem, Blue Shield, Health Net, and Oscar, but they will either not allow Lactation Consultants to join their network or claim their network is full for lactation.
Under the ACA, lactation support is considered preventative care and most health plans must cover these services without out of pocket costs to the patient, as long as they’re provided by an in-network provider. If you receive care from an out of network provider, you will likely incur some out of pocket cost. Depending on your out of network benefits, this amount may vary significantly.
For those who have an insurance plan for which I am NOT an in network provider, I do require payment at time of service and I will issue you a superbill (essentially a receipt of payment for medical care) that you can submit to your insurance company for reimbursement. Your ability to be reimbursed for our visit will depend on how your insurance company handles lactation claims.
Step 1: Start with calling the member services phone number on the back of your card. Ask for a list of local in network lactation consultants. If they are able to provide you with such a list (and the person/people on this list are actually IBCLCs providing lactation care, not just pediatricians or other doctors that don’t offer lactation specific support), you must use one of them in order to have your lactation care covered as preventative care. If they are unable to provide you with an in-network lactation consultant in your area, ask them how they handle reimbursing lactation care since they don’t have any in network options. There may be some plans that will reimburse you 100% of your out of pocket cost (this is more of an exception than the norm). If they tell you this, please ask them which of the following billing codes are accepted based on the diagnosis code and then to provide you with the “allowed amount” for each code. Please write down what they tell you next to each code and double check that they will reimburse the full amount of the allowed amount, not a percentage of it:
Diagnosis Code: Z39.1
Billing codes:
S9443
99344
99349
99404
98960
The majority of plans will default to reimbursing based on your out of network benefits. From here, you have two options.
Option 1. You can ask for a network/gap exception due to network deficiency. If they can’t provide you with a suitable provider who is a part of their network, their network is deficient, and they must allow you to see an out of network provider as if they were In network (so your reimbursement will be subject to your in network benefits). If they agree, they may send a form that we both fill in information for OR they may ask for the information of the provider you would like to see.
Provider Name: Ariana Lapierre, IBCLC
NPI:1306324058
Tax ID/EIN: 86-2457195
Contact Info: P: (949) 342-8181 F: (949) 342-8610 Email: ariana@beyondmilklactation.com
Diagnosis Code: Z39.1
Billing Codes: 99344, 99349, 99404, 98960, S9443
Visits: Ask for 6
During your phone call, please ask:
Which of the billing codes are accepted based on the diagnosis code and then to provide you with the “allowed amount” for each code.
What the next steps are (whether you need to forward the form to me or what needs to happen next).
For the name of the person you speak with, for them to make a note in your account, and to provide you a reference number for this phone call/issue.
Example of what your reimbursement may look like using Option 1:
Provider’s rate (paid out of pocket, up front): $225
Deductible: $1,500
Allowed amount (based on billing codes): $175
Co-insurance: 20%
The deductible and co-insurance are irrelevant because you are using your in-network benefits and this is preventative care. The allowed amount is $175. You should be reimbursed the full allowed amount: in this case you would incur a $50 out of pocket cost ($225-$175).
Option 2. Use your out of network (OON) benefits (if you have them). If you have an OON deductible that has already been met and a fairly low co-insurance amount, then you may be able to recover a significant amount of the cost of your lactation visit by using your OON benefits.
Understanding Out of Network benefits:
Out of network benefits allow you to obtain care from providers who do not have a contract with your insurance company. If your plan includes out of network benefits, this usually comes with higher costs (including a separate higher deductible and higher coinsurance). Your insurance plan will reimburse based on a percentage of their “allowed amount” for the codes that are billed.
First, it is important to understand what your deductible is and how much has been paid towards it. You will not be reimbursed from your insurance company until you have paid medical providers the full amount of your deductible.
Examples of what your reimbursement might look like using OON benefits:
Scenario 1: Deductible has not been met ($500 of $1,500 has been paid)
Provider’s rate:$225
Allowed amount: $175
Co-insurance: 50%
In scenario 1, since your deductible has not been met, unfortunately you will not be reimbursed. The allowed amount will be applied towards your OON deductible: $500+$175 —> $675 of $1,500 has been paid)
Scenario 2:
Assuming deductible has been met:
Provider’s rate (paid out of pocket, up front): $225
Allowed amount (for the codes on superbill): $175
Co-insurance: 20%
In scenario 2, since your co-insurance is 20%, insurance will reimburse the remaining 80% of the $175 allowed amount. Therefore the reimbursement amount is: $140, making your out of pocket cost the difference between the full price you paid for the visit ($225-$140= $85).
Scenario 3:
Assuming deductible has been met:
Provider’s rate: $225
Allowed amount: $120
Co-insurance: 50%
In scenario 3, since your co-insurance is 50%, insurance will reimburse the remaining 50% of the $120 allowed amount. Therefore the reimbursement amount is $60, making your out of pocket cost the difference between the full price you paid for the visit minus the reimbursement amount ($225-$60= $165)
FAQs:
Q: How do I know what my OON benefits are?
A: Two options:
You can either login to your online insurance portal and look for information regarding your OON benefits: it’s important to find the deductible as well as how much of the deductible has been met for the year and your co-insurance. Please make sure you are finding this info for your out of network benefits, not your in network benefits.
Call member services and ask them for this same information.
Q: How do I know what the allowed amount is?
A: You’ll need to call member services and ask them which of the following billing codes are accepted based on the diagnosis code and then to provide you with the “allowed amount” for each code.
Diagnosis code: Z39.1
Billing code:
S9443
99344
99349
99404
98960
Q: Why is there so much emphasis on asking for the allowed amounts for all these codes?
A: Different insurance companies prefer different codes for lactation visits or will reimburse high levels for some codes and low levels for other. For instance, one company may $75 for S9443 while another allows $125, and another allows $0. Some companies will only pay on 99404 and others will only pay on 98960. Finding out the allowed amount based on the diagnosis code (reason for the visit) is important to help ensure you get the highest reimbursement possible. I can often combine s9443 with one of the other codes.
Q: What about HMO plans?
A: If you have an HMO plan, you do not have out of network benefits, Please refer to Option 1 listed above. You’ll likely need a referral from your OB or baby’s pediatrician.
I do accept FSA/HSA cards and fee-for-service/self pay.
Contact me regarding discounted rates for those on WIC.
Please don’t hesitate to reach out with any questions you may have.