Medi-Cal recipients in the state of California have scored a big win, and we need your help in getting this good news distributed throughout your networks.
The state Department of Health Care Services issued a bulletin with explicit guidance on the coverage criteria for families to receive pasteurized human donor milk on an outpatient basis, effective Dec. 1, 2022.
By law, Medi-Cal has been required to cover medically necessary pasteurized donor human milk obtained from a licensed and approved facility since the 1980s. However, the question of what conditions count as “medically necessary” and what makes a facility “licensed and approved” have caused confusion among providers and Medi-Cal Managed Care Plans.
Attempts to clarify state policy under Gov. Pete Wilson in the 1900s still failed to secure consistent coverage of pasteurized human donor milk by Medi-Cal Managed Care Plans throughout the state.
Pauline Sakamoto of Mothers’ Milk Bank San Jose announced the new policy at the December 2022 Quarterly Coalitions Meeting, explaining how it will streamline the process for Medi-Cal families to access donor human milk for their infants through the state’s two nonprofit milk banks and for the milk banks to get reimbursement for the milk.
The new policy accomplishes the following:
- Specifies pasteurized donor human breast milk (PDHM) is billable with HCPCS code T2101.
- Identifies Mothers’ Milk Bank San Jose and UC Health Milk Bank in San Diego as “licensed and approved” providers of donor human milk under all Medi-Cal plans.
- Provides clear criteria for the circumstances in which prescriptions for donor human milk will be approved by Medi-Cal.
According to the policy, Medi-Cal providers can arrange for the provision of donor human milk for outpatient newborns in at least one of following situations:
- Infant has a documented birthweight of less than 1500g
- A congenital or acquired condition places the infant at risk for necrotizing enterocolitis (NEC) and/or infection
- Infant has a qualifying condition determined by the neonatologist or pediatrician
- Mother has a condition making their own milk insufficient in quantity or medically unsafe
- Mother’s milk must be contraindicated, unavailable (due to medical or psychological condition), or available but lacking in quantity or quality to meet the infant’s needs
Major changes to criteria and clarification of qualifying conditions
Though the criteria in the policy bulletin only mentions neonatologists and pediatricians, the Pregnancy: Postpartum and Newborn Referral Services provider manual update states, “Authorized providers who can prescribe PDHM are: physicians, advance practice nurses (Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives) and Physician Assistants.”
This gives any provider with prescription-writing privileges the authority to determine if the infant or birthing parent has a qualifying condition. It also clarifies the lack of quality or quantity of a mother’s own milk to be a qualifying condition. If a parent has difficulty with their milk supply, latching their infant, or the infant is not thriving, Medi-Cal must cover pasteurized donor human milk.
In a practical sense, the criteria also addresses situations such as when a mother or birthing parent might be hospitalized or undergoing medical procedures, prescribed medication not considered safe for breastfeeding individuals, or taking medication that might diminish lactation. Choosing certain types of medical treatment no longer requires parents to feed breastmilk substitutes if they would prefer human milk for their babies.
Medi-Cal families can request a prescription for pasteurized donor human milk from their provider and take that prescription to either Mothers’ Milk Bank San Jose or UC Health Milk Bank in San Diego to receive milk for their infant. Provided HCPCS billing code T2101 is used, Medi-Cal must honor the prescription and reimburse the milk banks accordingly.
Policy triggers updates to several provider manuals
The Medi-Cal provider manuals updated to include this new guidance are:
- Clinics and Hospitals General Medicine — epsdt (7); epsdt chdp (23); medne (17); preg com (6); preg post (7,8)
- Durable Medical Equipment — dura other (23,24)
- Home Health Agencies/Home and Community-Based Services — preg post (7,8)
- Inpatient Services — medne (17); ob rev instr (28); preg post (7,8)
- Obstetrics — epsdt (7); epsdt chdp (23); preg com (6); preg post (7,8)
- Pharmacy — dura other (23. 24); epsdt (7)
The challenge now, for everyone in the lactation community, is to make sure all families and providers throughout the state know and understand this new policy. Given the historical challenges with Medi-Cal approval and reimbursement, many providers mistakenly believe pasteurized donor human milk is not a covered benefit for families. And if all a provider does is read the DHCS bulletin, they may still not fully understand the full scope of the policy. Please read the provider manual updates above and quote from them when talking with members of your community.