Please Call your Insurance to Check Coverage
Insurance and Fee's
Many Insurance Companies will allow an IBCLC to bill directly.
As a reminder, it is ultimately your responsibility to know your benefits. You can find these out by calling your insurance company, reviewing the "summary of benefits coverage" that you received from your employer or when you purchased your insurance on the healthcare exchange. This can also be found on your insurance company's website, usually via a client portal. There is no guarantee of coverage. Anything that is not covered by insurance is your responsibility. You will pay for your consult at the time of booking and then your insurance company will be billed on your behalf. If and when your insurance pays Infant Instincts will reimburse your appointment fee or of the amount they pay if it less than the appointment fee.
Travel Fees are not covered by insurance and will be refunded or reimbursed.
Please Read all insurance information below
A superbill will be provided upon request if I am not able to bill insurance directly, you can then try to file a reimbursement claim with your insurance company.
Accepted forms of payment
Cash, Card, FSA/HSA
YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY
Being covered does mean free! Despite what any Aetna representative may tell you, your coverage for lactation benefits is completely dependent on your individual plan, which is dictated by your employer. Even if Aetna tells you that you are one hundred percent covered for lactation, they may assign you a copay or a patient responsibility for which you are responsible to pay us.
We invest every possible effort to get your claim(s) fully covered and we have an extremely high success rate. We have been in network since 2013 and have literally the most excellent and knowledgeable billers for lactation, who are truly dedicated and committed to avoiding any client cost share. We use the proper and most conservative billing codes available that have the lowest risk factor of triggering any cost share. We have been using the same correct codes since 2013. Despite what the Aetna rep may tell you, our codes are correct. At the end of the day, Aetna holds all the power and they adhere to the benefits your employer sets!
Our situation is unique as healthcare providers. We have two clients, not one. We bill for both you and your baby because in ninety-five percent of the consults we assess and make recommendations and a care plan for two clients. The exceptions are when we do prenatal consults and for some weaning consults where it is strictly the parent only. If your consult includes any discussion, assessment, and care plan for your baby we will bill accordingly for both of you.
We use multiple codes per service date because this is standard practice and the only way to bill for the complexity and or duration of the service provided. Using multiple codes does not bill multiple consults per date. This is incorrect and a tactic that Aetna uses to pin the client against the provider and to get away with not paying.
Any patient responsibility or copay that Aetna assigns you after we exhaust all requests for reprocessing is your financial responsibility to us and will be billed directly to the credit card you have on file with us unless you indicate you want to use a different form of payment within 24 hours of the issuance of your invoice in which case that new form of payment will be billed.
Aetna is in the business of making billions in profit per year. We are in the business of providing expert, culturally competent, compassionate infant feeding and lactation support to families and for this, we must be paid.
Thank you for the trust you extend us and for the opportunity to support you.
SELF PAY CLIENTS
The Affordable Care Act requires that all new health plans cover lactation support and supplies without cost-sharing “for the duration of breastfeeding,” which means plans may not apply any co-payment, co-insurance, or deductible to these benefits. Insurance companies can impose some limitations such as where to obtain the equipemnt and requiring the purchase, rather than rental, of a pump.
Private insurance: The relatively few exceptions are “grandfathered” plans that do not have to comply. The most effective way to find out if your plan is grandfathered or not is to call your insurance carrier and to ask. All plans purchased on the Health Insurance Marketplaces must cover lactation support and supplies.
Medicaid: Coverage for lactation support and supplies will vary by state and by type of Medicaid coverage.
Where to Start?
First determine if your plan is grandfathered or not. If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.
If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out of network exemption (or gap exemption). Make sure to ask for an exemption for several visits since most cases require 2-4 visits and more complex cases can require 6 visits. Here is the information you need from me to get pre-approval:
Provider Name: Jessica Hopp
NPI # 1710273859
EIN # 26-1945655
Address: 6228 Filbert Ave Suite 1 Orangevale, CA 95662
Diagnosis Code: Z39.1
Procedural Codes: OFFICE: 99404 and S9443 TELEHEALTH: S9443
Modifier: OFFICE: 33
Place of Service: OFFICE: 11
Write the date, time and NAME of the supervisor or agent who tells you that you are covered. Ask them to note your file and if possible to send you confirmation of the conversation and the information they gave you regarding the coverage under your benefits.
If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.
It can be useful to get a referral from your pediatrician and or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.
POSSIBLE SCRIPT TO USE WHEN CALLING: If your pediatrician conceded to giving you the referral then make sure to start the script with this information.
You: I understand that under the Affordable Care Act all plans are required to cover breastfeeding support and supplies without cost-sharing. Can you confirm that my plan follows this Federal guideline?
Insurance Agent: NO, we don’t cover breast pumps or lactation consultants.
You: Is my plan grandfathered?
Insurance Agent: NO, your plan is not grandfathered, but we don’t provide this benefit.
You: The healthcare law requires that you provide this benefit. Can I speak with a supervisor to make sure this is the correct information about this policy?
Repeat these questions to the supervisor and insist that under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding.”