If you’re pregnant or a new nursing mother, you know that you’re going to either need a breast pump or will have to switch to formula feeding if you are going to go back to work or spend more than a few hours apart from your baby. While breast pumps can range from $25 for a manual pump to $300 or more for a professional grade double electric pump, estimates show that the cost of buying formula can be upward of $1,200 for the first year. The cost savings of breastfeeding is clear even if you need an expensive pump, but you may qualify to receive a free breast pump thanks to the Affordable Care Act.
The Affordable Care Act began rolling out in 2012, and part of the act is aimed at giving people better access to preventative care, which includes helping pregnant women and new moms pay for lactation support and breastfeeding equipment, i.e. breast pumps. While the health care law requires insurance plans (except grandfathered plans*) to pay for breast pumps and lactation support. The details of which breast pumps are covered is left up to the insurance companies to decide, as is whether each plan will cover manual or electric pumps, the rental or purchase of a pump, and how you have to go about getting the pump. Since this policy is relatively new, insurance companies and medical providers are still trying to navigate this coverage, which can make it difficult for consumers to get answers on how to secure this benefit.
The first step is to contact your insurance company, because all policies are different. I found it easiest to send an email inquiry so I’d receive a response in writing, which I could refer back to when the time came to purchase my pump. In an email response, the insurance company told me that I was covered for the purchase or rental of any pump that was ordered through an in-network physician, hospital or durable medical equipment provider. The email came with a list of in-network durable medical equipment providers. I contacted a few to find out which pumps they could provide so I could research which type I wanted, so that I’d be able to place my order right after the birth of my son. Thanks to meeting with the lactation consultant while I was still in the hospital after the birth, I discovered that the hospital uses a local in-network provider, and had the pumps in hand. The hospital and provider took care of the paperwork and I went home with a new baby and a new breast pump.
Here are some questions you should ask when you contact your insurance company to find out your coverage.
- What types of pumps are covered? Does your coverage apply to the purchase or rental of a pump, or both? Are you limited to a specific brand or type of pump, or is there a maximum dollar amount that will be covered? If only a rental is covered, for how long does the coverage apply?
- Will I need to qualify for the coverage to apply? Some health insurance companies require that a pump be deemed medically necessary to qualify for coverage. You may need a prescription from your doctor and/or need to wait until after the birth to order a pump. The medical equipment provider may ask the name and phone number of your doctor so they can verify the birth of the child and need for a breast pump.
- How do I order or purchase a pump? Many insurance companies have consumers order directly from a covered DME provider, which bills the insurance company directly. DME providers may be local or online, and they don’t carry the same pumps, so you may need to call around to see if the pump you prefer is available at one in your network. Some pump manufactures aren’t able to keep up with the demand for covered pumps, so they may be unavailable or on back-order. Other insurance companies may require that you purchase the pump and receive reimbursement.
- Are there stipulations to the coverage? Will I have to pay a co-pay or meet my deductible? Most women shouldn’t have to pay a co-pay or deductible, but in some cases, going to an out-of-network DME provider may mean that your breast pump is not covered at all, or that you may have to pay a higher co-pay than if you used an in-network provider. If you choose to purchase an upgraded pump (double electric vs. manual), you may also be responsible for a deductible or co-pay.
If the coverage doesn’t meet your needs, your doctor may be able to help. In many cases, your insurance plan will follow your doctor’s recommendations on what is medically appropriate. For example, if your plan will only cover a manual pump and you will be returning to work full-time, you may not be able to pump enough to sustain your baby on breast milk. Your doctor may be able to specify that a double-electric pump is medically necessary. You still may not have the choice on whether a purchased or rented pump is covered, or which type of pump you can receive, but you’ll have a better case if your doctor will get involved.
If the pump of your choice isn’t covered by your insurance plan and you wish to purchase one on your own, and have a flexible spending account (FSA) or a health spending account (HSA) through your job, the cost of a breast pump is a covered expense. While my insurance company covered my double electric pump, I elected to also purchase a manual pump for $30 so that I would have one that is more portable and able to be used without battery or electricity. I received reimbursement through my FSA by submitting the store receipt.
Finally, if you are determined to breastfeed your infant, but your plan doesn’t cover the rental or purchase of a double electric pump, you should considering registering for, or purchasing a pump on your own. Having a good pump may help you keep up with the nutritional needs of your baby and may save you the $1,200-plus expense of purchasing formula for the first year.
*If your insurance plan is grandfathered, you may not be eligible for some of the rights and benefits stipulated in the Affordable Care Act. Grandfathered plans “are those that were in existence on March 23, 2010, and haven’t been changed in ways that substantially cut benefits or increase costs for consumers.” Insurers must notify consumers with these policies that they have a grandfathered plan.
It’s not really a “free” breast pump unless you have $0 out-of-pocket expenses, which most people will not.
Val McCauley says
Everyone’s insurance is different, as I mentioned, and some plans are grandfathered in and do not have to comply. My pump was completely free, and everyone whom I’ve talked with also got theirs completely free (at least 20 different women with various insurance plans). From the ACA website “Your health insurance plan must cover the cost of a breast pump – and may offer to cover either a rental or a new one for you to keep”. According to that, I believe the insurance plans must cover a pump without a co-pay, but they can choose what kind (manual or electric), and whether it’s rented or yours to keep. The out-of-pocket expenses may come into play if you chose to receive a different model than the covered. one, or to purchase instead of rent.
The law doesn’t have specifications in place, so it is open to interpretation by each insurance company, thus coverages may vary widely and there is no one source of exactly what is covered and how to obtain the coverage.