Like most things related to health care and insurance, the details of the requirements for insurance companies to cover breast pumps are really confusing. To illustrate how difficult it is, I tried to find the actual text of the provisions covered by the law in the Affordable Care Act. Since it is 955 pages long, I did a search for “breast,” which comes up 44 times in the law. Two of these refer to allowing breastfeeding mothers to take reasonable breaks to pump at work. The other 42 references are in regard to breast cancer.
So where does the law actually state what insurance companies must provide? This is the closest that I can come to finding it:
Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.
So that’s super clear, right? There is no definition of what “breastfeeding equipment” consists of, and as far as I can tell, this is the entire text of the provision. (If you know of a place in the law where this is more clearly detailed, let me know!)
Some more details I was able to find on this topic:
Does my insurance company have to cover a breast pump now, under the Affordable Care Act?
In most cases, yes. The only situation where this rule does not apply is if you have a grandfathered plan. Grandfathered plans are plans that were in place on March 23, 2010 and have not changed substantially since then. Your insurance company must notify you if you have a grandfathered plan. The rules do not vary by state, so the insurance company needs to cover a pump regardless of where you live.
The insurance company is not allowed to charge you a deductible or co-pay.
When can I get the pump?
Most policies (89%) provide the pump after the baby’s delivery. (Source: Medela’s survey of insurance companies.) This is kind of a bummer if you need it when you get home from the hospital – I used mine right away to try to stimulate milk production. Also, I was way too out of it at that point between sleep deprivation and hormones to be dealing with my insurance company. If you can, it’s probably a good idea to work out the details with your insurance company before you have the baby so you can get it as soon as you have the baby, and so you don’t have to figure it out when you’re dealing with all of the post-partum stuff.
Do I get to choose the pump that I want?
It depends on your insurance company – some offer choices and some do not. Some will only cover a manual pump, others will allow you to purchase a double electric pump, and others will cover rental of a hospital grade pump. Here are a few details that Medela got from their survey of insurance companies:
- 77% cover hospital grade pump rental, but most of them require pre-authorization and a prescription. You can get this from your OB or baby’s pediatrician. The insurance company determines how long the rental pump is covered. (Does that mean they can just cover it from one month and call it a day? Probably not, but I’m not sure the text of the law prevents that.)
- 60% of insurance plans will allow an upgrade. If your plan offers a basic pump and the one that you want is more expensive, they’ll allow you to get the more expensive one and just pay the difference.
The ACA website says that the insurance company determines whether they pump that will be provided is manual or electric, which – as an exclusive pumper – means that if you get stuck with just a manual pump you’ll probably need to see if you can upgrade, or you’ll have to pay for the full cost of the pump out of pocket.
Do I just go to the store, buy a pump, and send my insurance company the receipt?
In most cases, no. Many insurance companies will require you to go through a medical device company. Aeroflow is a good example of this – you can go to this page and see if they take your insurance and then what pumps you would qualify for. You do not have to pay for the pump, that should be handled between the insurance company and the medical device company.
If your insurance isn’t on Aeroflow’s list and you don’t know where to start, call your insurance company and find out who they work with.
This is still really confusing and I don’t know where to start.
I know. Your best bet is to call your insurance company and ask how to get your pump covered by insurance. (Here is a good list of questions to start with.) My best piece of advice: since this is new for most insurance companies, be prepared for the person you’re talking to to not know what they’re talking about. If you don’t like the answer you get, call back later and see if you have better luck.
I bought all three of my pumps (yes, three) with my first baby, before the ACA went into effect. How has getting your pump from through insurance worked out for you?