Insurance FAQ

Does The Breastfeeding Center accept insurance?

Yes. We currently are able to accept most Aetna, BCBS/Carefirst, and United insurance plans for visits with our lactation consultants. However, we always suggest giving your insurance company a call to see how lactation care is covered under your particular plan.

Some plans may require some amount of “patient responsibility,” e.g. a copay, coinsurance, or apply a deductible. We will bill your insurance company, and follow up with you by email with an invoice if your insurance determines any amount of “patient responsibility.” In our experience, it is only some plans (25-50% of our clients) that experience a copay/coinsurance/deductible, and the amount typically ranges between $15-75 per appt. Your usual specialist deductible would be a good gauge of the amount you could potentially expect to pay-if anything at all.

Please understand that the Travel Fee of $100 (for home visits only) and all breastfeeding or pumping supplies used must be paid for by you, out of pocket, and cannot be billed to your insurance.

What if I don’t have Aetna, BCBS/Carefirst, or United? Or what if I don’t have Aetna, BCBS/Carefirst or United as my primary insurance?

Even if you don’t have Aetna, BCBS/Carefirst, or United, or do not have them as your primary insurance, lactation care is STILL required to be covered for you under the Affordable Care Act, “fully and with no cost-sharing” for the duration of breastfeeding. We will provide you with the forms to submit to your insurance company for reimbursement.

If reimbursement is important to you, then we STRONGLY suggest you call your insurance company ahead of your appointment. Please thoroughly review this toolkit from the National Women’s Law Center and this FAQ from the U.S. Dept. of Labor on Lactation Coverage under the ACA to understand what the law requires your insurance company to cover, and how, before you call them. Sometimes we find that insurance company representatives are not fully aware of ACA’s provisions regarding breastfeeding care.

Again, under the Affordable Care Act, lactation consults are required to be covered fully and with no “cost sharing”(except for the very few “grandfathered plans”)—meaning that you should not have to share the cost of your consult with your insurance company. They should cover it fully. However, despite being required by law to cover lactation care since the implementation of the ACA, no insurance companies besides Aetna, BCBS/Carefirst, and United have added IBCLCs into their network, which is why we cannot accept your insurance directly. The absence of in-network providers available to you means that your insurance company must cover out-of-network providers as though they were in-network.

Clients who have an insurance company or plan with whom we are NOT in-network (or an out-of-network insurer/plan, with an in-network insurer as a secondary) must pay at the time of their consult for their appointment. As of September 1st, 2018 the out-of-pocket cost of a prenatal office visit is $100, a postnatal office visit is $200 and the cost of a home visit is $300 ($200 for the consultation and a $100 travel fee). We will provide you with the forms to submit to your insurance company for reimbursement after your appointment.

Consult Type Length of Time Payment if Out of Pocket*** Billable to Insurance**
Prenatal Consult 30-45 min $100 for some plans
Office Visit 60-75 min $200 yes
Home Visit* 60-75 min *$200 yes
*Home Visit Travel Fee $100 no
Phone Follow Up Questions ~10 min included w/ consult for 30 days no
Video-Call Consults (only for established clients) 10-75 min, prorated $200/hour yes
Cancel, Reschedule, or No-Show within 24 hours of appt $100 no
*Travel Fee applies for all Home Visits. Please understand that insurance companies regard this as the client’s responsibility and do not reimburse for it.
**If “yes” or “maybe” for this column we will bill your insurance company directly for clients with Aetna, BCBS/Carefirst, or United. For clients with any other insurance provider, you will pay out of pocket and we will provide you with forms to submit for reimbursement.
***If the out of pocket cost, or your type of insurance coverage is prohibitive to the care you and your family need, please call to ask about our Sliding Scale or our Volunteer Trade Hours Programs.

I have an appointment scheduled. Should I call my insurance company before my appointment?

If 100% coverage, or full reimbursement is important to you, then we STRONGLY suggest you call them. Just call the phone number on the back of your insurance card and have your insurance ID number ready. Some plans may require a pre-certification or gap exception. Please review the NWLC Toolkit on breastfeeding care, and DOL FAQs to understand what the law requires your insurance company to cover.

We suggest that you ASK your insurance company for a list of in-network providers for lactation consultation, if cost is a concern and they are able to provide you with an in-network option you should consider that first. However, most will not be able to provide you with a list of any in-network options for lactation care. Again, if they do not have in-network providers, the law requires them to cover out-of-network providers fully. If you have Aetna, BCBS/Carefirst, or United and they indicate that we are not in-network, please call us or ask to confirm this information with a supervisor. The Center is in-network for most, if not all, plans within these networks.

What is a pre-certification and how do I get it?

A pre-certification is the process of getting approval from your health plan before you have any health procedures performed. Getting pre-certification for certain procedures helps you and your provider know what is covered by your health plan before any services are performed. For lactation consultations, it also often means a higher rate of reimbursement from your insurance company. 

To get a pre-certification, you will just need to call your insurance company, tell them you have an appointment scheduled with us, and check to see what information they need. If we are not in-network with your insurance company, we will not be able to call them on your behalf to get this pre-cert, it will be something you have to call to have put in place.

Some of our clients have found this information helpful:

Our Address: 1020 19th St NW, Suite 150, Washington, DC 20036

Our Tax ID: 83-0575270

Our Billing NPI: 1427534783

What is a gap exception and how do I get it?

A gap exception is something you can request from your insurance company when your insurance company does not have any provider within a certain amount of miles (typically 30), or if they do not have enough providers with available appointments within that area, for a service that they are required to cover. Insurance companies are required to cover lactations consultations under the ACA. A gap exception can help facilitate your full reimbursement when going to an out-of-network provider like the Breastfeeding Center.

To get a gap exception, you will just need to call your insurance company, tell them you have an appointment scheduled with us, and check to see what information they need. If we are not in-network with your insurance company, we will not be able to call them on your behalf to get this gap exception, it will be something you have to call to have put in place.

Some of our clients have found this information helpful: :

Our Address:1020 19th St NW, Suite 150, Washington, DC 20036

Our Tax ID: 83-0575270

Our Billing NPI: 1427534783

Some plans may also require the gap exception to be called in by an in-network, referring provider, such as your OBGYN, midwife or PCP.

How do I schedule an appointment?

Please call us at 202-293-5182 to schedule an appointment or for more information.

We cannot guarantee reimbursement from any insurance company. Please always call your insurance company for the most up-to-date information.

We offer private appts prenatally through weaning! Schedule Here!
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