Aetna

TL;DR Aetna is no longer fully covering 6 lactation visits with no out of pocket costs, even though they claim that they cover lactation “with no copay or out of pocket cost”. You may have to pay a co-pay or coinsurance for our office visit(s), and all virtual visits must be 30 minutes or shorter.

As of Sep 1, 2024 Aetna is drastically cutting back their lactation coverage for their subscribers.

In the past Aetna would cover up to 90 minutes of a lactation consult with an IBCLC, whether in person or virtually, by allowing us to use a feeding problems procedure code to bill half of the appointment time to the baby and the other half to the parent (since of course we always have at least TWO clients for lactation visits).

This meant that most of the time, lactation services were covered 100% by Aetna with no copay or deductible (as required in the Affordable Care Act). You could see an IBCLC 3-6 times with no out of pocket cost depending on your plan.

But as of Sept 1, Aetna will no longer cover a full IBCLC consult in person- they won’t let us use the feeding problem procedure codes anymore. Instead they will only cover a lactation “class” for parent (and sometimes also for baby). This severely limits how much time I can spend with you, and how much care I can provide for you with no out of pocket cost.

This lactation “class” code was made to cover the lactation class you may take at the hospital, birthing center, etc. These classes are given in group format and they’re not personalized.  Many pump companies like Aeroflow now offer customers “free” lactation classes on demand and bill them to your insurance using this class code.

A lactation “class” is very different than a 1:1 lactation consult. The lactation class code covers about 30 minutes of appointment time.  There is almost no way I can provide the clinical care you and your baby deserve and need in a 30 minute office visit. 

Aetna is still allowing me to bill one additional procedure code for our office visit based on how much time we spend together, but that amount may be applied to your deductible or you may need to pay a co-pay or coinsurance.

Therefore as of Sept 1, 2024, any office visit with me that lasts longer than 30 minutes may trigger a co-pay or coinsurance. I collect your credit card information at the time of booking and will submit your claim to Aetna. If there is any patient responsibility, I will notify you before charging your card on file. You will never be billed for more than the cash visit price of a consult.

Now, on to virtual consults- Aetna has also decided that as of Sept 1, virtual visits will only be covered as a “class” and nothing else. I have no other billing options, so as for right now, I can only do a 30 minute virtual consult. That’s really not enough time for anything more than a Q&A session/mini consult on one issue. I will no longer be able to do full virtual bottle refusal visits for Aetna subscribers.

How do you avoid co-insurance or copays for lactation visits? Call Aetna member services and confirm that your plan has lactation coverage, then confirm if you have used any of your lactation benefit already. Sometimes companies who work with your insurance (like Aeroflow and other breast pump providers) will bill your insurance for any “free” classes they provide and this uses up part of your insurance benefit. 

I am trying very hard to find a way to make this work so I don’t have to drop out of the Aetna network. Please feel free to contact my office with any questions by emailing hi@rachelobrienibclc.com 

And if you’d like to speak up and let Aetna know how you feel about this change, click here https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm