Does The Breastfeeding Center accept insurance?
Yes. We currently are able to accept most Aetna and United insurance plans for visits with one of our lactation consultants. However, we always suggest giving your insurance company a call to see how lactation care is covered under your particular plan. If your particular plan does not cover 100% of your consultation as the Affordable Care Act requires, we will notify you after your consultation and you may choose to pay the difference out of pocket, or take advantage of our sliding scale or volunteer trade hours program.
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 or United? Or what if I don’t have Aetna or United as my primary insurance?
Even if you don’t have Aetna 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 consultations 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 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 a non-Aetna/United insurance company (or a non-Aetna/United primary insurance company with Aetna or United 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|
|Skype or Facetime Consults||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 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 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 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 will 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.
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.
Some of our clients have found this information helpful:
Our Address: 1020 19th St NW, Suite 150, Washington, DC 20036
Our Tax ID: 522128320
Our Billing NPI: 1124237078
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 a provider within a certain amount of miles (typically 30) 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.
Some of our clients have found this information helpful: :
Our Address:1020 19th St NW, Suite 150, Washington, DC 20036
Our Tax ID: 522128320
Our Billing NPI: 1124237078
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.