At our WIC office in Sacramento - like many throughout the country - a lot of time is spent dealing with breast pumps – cleaning, inventory, follow-up, issuing to and teaching participants how to assemble and use, training staff, communicating with and educating providers, etc. All this despite the fact that both the cost to rent or purchase a breast pump has been listed as allowable items to bill for under Medi-Cal for many years. One can imagine the excitement in the WIC world when the Affordable Care Act (ACA) passed, requiring health plans to cover “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” At last, WIC could focus more time and money on breastfeeding promotion and support, instead of running a breast pump depot!
In the meantime, durable medical equipment (DME) companies began popping up, advertising personal-grade pumps for mothers by way of an easy-to-complete prescription form, after which the pump would be shipped directly to the mother. Cautiously optimistic, we set out to learn more about the process, and figure out how to connect WIC mothers with breast pumps, so that staff and IBCLCs alike could point mothers in the direction of her very own electric breast pump.
The process for obtaining a breast pump through the ACA should, in theory, be simple:
- the mother obtains a prescription for the pump from her OBGYN, primary care provider or her baby’s pediatrician
- the prescription includes a qualifying diagnosis with an appropriate ICD-9 code
- the prescription is submitted to the health plan or DME
- the pump is shipped to the mother at no cost to her
We began by calling the Medi-Cal managed care plans and commercial health plans available in Sacramento County to find out how a member would go about getting a breast pump through insurance. We also called the DME companies behind the prescription forms to better understand their process and determine which health plans they were contracted with in our county. What we began to learn was that because no regulations have been written yet for the breastfeeding support provisions of the ACA, insurance plans and medical groups are making up their own guidelines about what they will cover. The process to obtain a pump is much more complex than we first realized.
As the California WIC Association reported at the California Women’s Summit in January 2014, “Many details have been left up to the health plans and have not yet been clarified…There has been widespread confusion about the provision of breast pumps, including when one is needed, and what type and quality to provide.” We found a confusing, complicated and inconsistent process that made accessing the ACA benefit extremely difficult for many, and completely impossible for some. It became very clear that several gaps existed and needs were not being met for specific groups:
- Emergency Medi-Cal was not required to provide this benefit
- Our local Kaiser Medi-Cal managed care members were not included in this benefit
- TRICARE is currently not required to cover this benefit
- Grandfathered plans (those in existence before March 23, 2010) are not required to cover this benefit
- Many health plans are providing all members with a personal-grade electric breast pump, regardless of need. In the event a hospital-grade pump is needed for a hospitalized infant or other feeding issue, coverage for renting such a pump is extremely limited or excluded.
Adding to the challenges in the process are the varying ways with which doctors’ offices interact with the health plans, a lack of education throughout all levels of the process, and inconsistent availability of breast pumps by DMEs.
- The process for accessing breast pumps varies between health plans, and is also dictated by how the medical practice is structured. For example, some health plans require the mother to work with her specific medical group/Independent Physician Group (IPG), instead of directly with the health plan, which creates an additional step and increases confusion.
- Many healthcare providers – who are being asked by both health plans and patients for prescriptions for breast pumps – are completely unaware that this benefit even exists, so often will refuse to provide a prescription.
- Although the health insurer must cover breastfeeding equipment and supplies, it has some discretion to determine the scope of this coverage by implementing “reasonable medical management techniques to determine the frequency, method, treatment, or setting” for the coverage, leaving much opportunity for interpretation.
- Some health plans have contracts with DMEs that do not stock or provide breast pumps. Many DMEs that provide other pieces of medical equipment for health plans refuse to provide breast pumps due to cost, staff training and lack of adequate reimbursement from health plans.
Despite the confusion and challenges, many WIC mothers have successfully obtained a personal-grade electric breast pump through the ACA at no cost. This has allowed them to return the WIC pump they were borrowing, or bypass the WIC breast pump all together. Even more WIC mothers have been educated on this topic, so they are equipped with the knowledge to pursue this benefit should they need it. Additionally, WIC has begun sharing this information with doctors’ offices and hospitals in the Sacramento-area, and plans to continue to educate providers about this benefit and how to help their patients access it when needed.
The inclusion of breastfeeding services and supplies in the ACA is sorely needed; however the process desperately needs to be clarified and streamlined, so as not to present mothers with additional barriers to continuing breastfeeding. Until then, WIC remains essential to meet the breast pump needs of eligible women. In Sacramento, we will continue to educate mothers and providers about this benefit and how to access it, and work to forge relationships with health plans to clarify the process and advocate for a consistent approach between health plans, medical groups, DMEs and others involved. We hope one day soon the process will be simple and streamlined, and eventually the medical community will be the leading source for breastfeeding supplies and support. In the meantime, more work is needed throughout California and the country, to identify the current systems in place and the challenges contained within that system. With patience and persistence, this aspect of the ACA will soon serve mothers and infants in the way the law intended.
If you’re trying to sort out how the ACA impacts your breastfeeding community, here are a few resources that may be helpful in the journey:
- California WIC Association (CWA)
- National Women’s Law Center
- Model Policy: Payer Coverage of Breastfeeding Support and Counseling Services, Pumps and Supplies