Understanding Lactation and Insurance Coverage

This page has information for both in-network and out-of-network patients - please see below for Aetna-specific (the info there can also relate to other policies too - in- and out-of-network).

Lactation visits are covered as preventative care by both Federal (the Affordable Care Act (ACA) and the State of NJ (other than some “grandfathered” policies). However - because many insurance companies do not effectively inform clients (or 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 none in your area, ask for an out-of-network exception (sometimes called gap exceptions, NAP, or other names).

  • If you are limited to a low number of visits, request more coverage. Getting a note from your and/or your babies doctor can help - have them include diagnosis codes to helping - including but not limited to P92.9 (Feeding problem of newborn), Z39.1 (Lactation care, mother) and Q38.1 (Ankyloglossia/tongue-tie)

• Red-flags to watch out for:

  • If they tell you visits are covered only with your OB or pediatrician - they are wonderful doctors, but they are not lactation specialists!

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

• If you submit your claim and it’s not covered:

  • Call and explain that lactation is preventative care - very often they will say “oops” and cover the visit.

  • If this does not work:

    • Helpful info and script from the National Women’s Law Center - “New Benefits from Breastfeeding Moms: Facts and Tools to Understand Your Coverage under the Health Care Law” and “I still have to pay out-of-pocket for my Lactation Consultation”

    • Re-ask about the other codes listed above (in the event that some codes may be covered more effectively than others)

    • Ask for a patient representative to help manage your case.

    • 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).

• Here are helpful insurance pages from other IBCLCs - The Lactation Place, Lucky Baby Lactation, and Rachel O’Brien (Rachel also has two more articles - one, two). Some of the info is already covered above, but those pages are very thorough as well and may be updated to include new ideas.

• Finally - if your insurance company does the wrong thing and does not reimburse or cover enough visits, or if you just decide it’s too much effort - please know that lactation visits have tremendous value no matter what - getting the help you wanted sooner rather than later, potentially saving future costs (formula, future oral therapies, dental issues) and so much more

Aetna and other in-network Coverage

Lactation Solutions of Princeton is currently in-network with:

This section focuses primarily on the idea that Aetna tells patients that they have “6 fully covered visits” - this is not entirely true. Here's a comprehensive breakdown of why you may not get 6 fully covered visits. Note - the info here may be relevant to other insurances as well (in- and out-of-network):

• Aetna's "6 fully covered visits” actually refer 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), this 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. A 2-hour visit typically is coded with 99404 and S9443 for both parent and baby.

• Some policies may count each use of the S9443 code as a separate visit, effectively reducing full coverage from 6 to 3 visits. Keep in mind there is almost always partial coverage once this occurs, so it’s unlikely you would be billed for a full visit (more likely something around $75 per visit).

• Baby's coverage varies for a few reasons:

  • The Affordable Care Act (ACA) covers lactation as preventative care for the parent, but does not specify babies. This means some policies will pay in full for the baby, while others will trigger deductibles, co-pays, or co-insurance (this can be anywhere from $5-$100 per visit, depending on your policy).

  • 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 of codes recognized as usable by IBCLCs. So, even though the code is clearly preventative in nature, their system does not recognize it.

  • The State of NJ however does specify the whole family as covered for lactation - using this info, sometimes insurance will agree to pay the above fees.

• Other situations that will likely reduce your coverage or trigger patient-responsibility:

• Online lactation classes (even prenatal ones offered by Aeroflow and other pump companies - see below for how to get those reversed if needed)

• Previous IBCLC visits (prenatal or after the baby arrived) will likely have billed the S9443 code time - reducing your pool of 6 uses. reducing your remaining number of covered visits. Note that hospital lactation services in the postpartum unit rarely use this code.

• If only the parent, and not the baby, has in-network insurance, additional charges will apply (the full visit cost (see FAQ page) minus what the in-network policy will pay for the covered parent)

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

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

• Take action:

• Contact your insurance company to advocate for more coverage. For example, most people are completely unaware that companies like Aeroflow (and others) used up coverage for their prenatal classes. You have the right to ask for those claims to be reversed, especially if you were unaware that they were used!

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

• Ask for a health concierge to help you (many polices provide them). They can help navigate appeals, and work with both you and your provider at the same time.

• If necessary, escalate your call to a supervisor to support your case.

For each visit, I will submit the claim and - if claims are not covered as they should be - can sometimes do an appeal. Any fees that are not covered will be billed for using your credit card on file. I can provide a good-faith estimate before your visits - please ask!