Know what is covered
Lactation (breastfeeding) counseling and supplies are an integral part of maternity care in the hospital setting. The Affordable Care Act (ACA) now requires non-grandfathered plans to cover, at no cost to the member, comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period.
Lactation counseling provided by a contracted provider, (i.e., primary care practitioner) in the office or clinic setting is eligible for waiver of cost share. Lactation counseling provided by lactation counselors outside the hospital setting is not eligible for coverage.
ACA COVERAGE DETAILS for breastfeeding supplies:
- MANUAL BREAST PUMP (E0602) covered with no member cost share:
- Claim must be submitted by contracting durable medical equipment (DME) provider.
- Some Target and Wal-Mart stores have DME contracts with Wellmark.
- One pump per birth.
- ELECTRIC AND HOSPITAL PUMPS (E0603-E0604) available with cost share:
- FIVE-YEAR LIMIT APPLIES (Replacement equipment is only covered at the end of five years, and when certain criteria are met. See the HME, Orthotics, and Prostheses guide on Wellmark.com (Provider > Billing Guides).
For more on women’s preventive care under the mandate, see the “Gynecology and Maternity” section of the Practitioner Guide on Wellmark.com (Provider > Billing Guides).
The ACA gives businesses and individuals the right to keep their current coverage. Employer groups and individuals that retain the coverage they had before March 23, 2010, are considered “grandfathered,” and are exempt from many provisions of the mandate. Always check a member’s eligibility and benefits, using the Eligibility Verification and Benefit Inquiry tool on Wellmark.com. To learn about benefits for Federal Employee Program members, please refer to the 2013 Benefits Brochure on FEPBlue.org.