Infants, Families Pay the Price for Gaps in ACA Coverage

May 1, 2023

Under the Affordable Care Act (ACA), new or “ungrandfathered” health insurance plans must cover breastfeeding supports and supplies as a preventive benefit without imposing cost-sharing, such as deductibles, copayments, or coinsurance.

Few plans are grandfathered, which means most insured Californians get these benefits at no out-of-pocket expense. However, eligible families and contracted providers in California are still being denied these benefits or being put through complex processes to access them. Participants from throughout the state shared their frustration and frustrating experiences at the April 27 Lactation Action Network (LAN) meeting.

Combined, the experiences shared by LAN attendees point to two issues:

  1. The law has loopholes that insurance companies exploit.
  2. There is no standardized enforcement of the law.

For instance, the law requires insurance plans to cover breast pumps but doesn’t specify the type or quality of pumps that must be covered, or when the pump can be acquired. Decisions the law allows insurers to make without oversight:

  • Coverage of manual pumps vs. electric personal-use or hospital-grade pumps.
  • How, when and where covered pumps are ordered.

Tricare West, the insurer for military families in California, covers breast pumps from 27 weeks gestation until 3 years after the event of birth. United Health Care doesn’t specify when they’ll cover pumps on their website, but contracted suppliers report the insurer only covers pumps ordered up to 30 days before a baby’s due date. San Mateo County’s human resources department notice to employees demonstrates the difference in coverage between Blue Shield and Kaiser plans.

Accessing covered breastfeeding support and education services is another challenge for families. Some insurance companies require the use of in-network providers, and yet have no in-network providers or no in-network providers within a reasonable distance. Private practice non-RN lactation consultants consistently have claims denied. Families are sent to WIC for help as a default, even if they aren’t eligible for WIC services. 

And if these experiences weren’t troubling enough, many providers see an entirely different set of rules for Medi-Cal managed care plan members compared to privately insured members from the same health plan.

Given the limited window of time families have to successfully initiate lactation and develop a mutually beneficial feeding rhythm, these are problems with a direct impact on the breastfeeding rates in our state.

Our next step is for Lactation Action Network members to contact their local legislators to find out whether they are aware of the barriers to coverage under ACA in their districts. If you’re interested in participating in this type of advocacy, you can join the LAN using this online form.

And if you have your own experiences to share related to access to the lactation benefits in your community, reply to this email and let know what you are seeing. Positive, negative and neutral experiences are all important for us to hear, so we can get a clear picture of what is happening right now throughout the state.