In-network with Aetna, CDPHP, and UnitedHealthcare

Aetna

Always best to call your insurance company to check for yourself, but our experience with Aetna has been:

• Coverage varies by plan

• You may owe a co-pay, co-insurance, or deductible

• We bill for both the parent and the baby, using a variety of codes based on the amount of time we spend with you and they type of care you require

• See Q&A below for more information about using your Aetna insurance

CDPHP

Always best to call your insurance company to check for yourself, but our experience with CDPHP has been:

• Fully covered (no copay, deductible, etc.)

• Unlimited number of visits

• Same coverage for all plans, including CDPHP Medicaid

• We bill only for the parent and use code S9443

What is the process for using my insurance? If you provide us with your Aetna, CDPHP, or UnitedHealthcare insurance information for yourself and your baby, we will send claims to your insurance and your baby’s insurance. You will not pay anything at the time of your visit. After your insurance processes the claims, you will be sent an invoice for any amount they’ve assigned to patient responsibility (like a copay, co-insurance, or deductible). Cost-sharing (copay, co-insurance, or deductible) is common with Aetna. We do not see cost-sharing applied with CDPHP or UnitedHealthcare.

I called Aetna and they told me I am fully covered for 6 lactation visits. There’s more to it. What they meant was that they will cover the S9443 code in full for 6 uses. Each time we meet with both you and your baby, we bill S9443 (and other codes) for each of you, so each visit uses 2 of the 6. Be aware that some providers of online breastfeeding classes may use the S9443 code, and we’ve had clients who had already hit their limit on S9443 before working with us. After 6 uses of S9443, Aetna will apply the fee for S9443 ($71.50) to patient responsibility. The other codes that we use for Aetna might have a copay or co-insurance, or might be applied to your deductible. After your claims are processed, we will send you an invoice for any amounts assigned to patient responsibility.

What if my baby is on a different insurance plan than me? When the lactating parent has coverage through Aetna or UnitedHealthcare and the child is on a different insurance plan that is not Aetna, UnitedHealthcare, or CDPHP, you will pay a fee for the child at the time of your visit. A superbill will be provided, which you can use to submit a claim for reimbursement to the child’s insurance company. The fee is $125 when the lactating parent has UnitedHealthcare, or $71.50 when the lactating parent has Aetna. There is no child fee when the lactating parent has CDPHP. The fee does not apply for Prenatal Consults.

What is the process if I have a different insurance company? For all other insurance companies, we do not bill insurance for you, but we will provide you with a superbill that you may use to file a claim with your insurance company. You will provide payment to us, and then you may seek reimbursement from your insurance.

If reimbursement is important to you, we strongly encourage you to check with your insurance company about your coverage prior to scheduling an appointment. You may want to ask things like:

• Do they have any in-network lactation consultants who can come to your home?

• If they don't have any in-network LCs, will they fully reimburse you for an out-of-network LC?

• Do you need to obtain prior authorization?

• What information do they need from you to obtain reimbursement? Is there a form?

If you plan to schedule a video consult, be sure to ask specifically about your coverage related to telehealth lactation support.

More information about legal requirements for insurance companies to cover breastfeeding support services can be found here.

I have The Empire Plan / NYSHIP and they’ve told me I can be reimbursed for seeing any lactation consultant. How does this work? Though we are out-of-network with The Empire Plan, it has been our experience that clients are reimbursed in full for an unlimited number of home visits. You will pay the standard fee at the time of your visit. Rather than providing you with a superbill for you to request reimbursement, we can submit the claim directly to The Empire Plan for you. Our clients have told us that they typically receive a check from The Empire Plan reimbursing them in full about 3 weeks after their home visit, though we’ve sometimes seen it take up to 3 months. Telehealth visits are only partially reimbursed.