How to get reimbursed for an IBCLC home visit by your health insurance company
As I’ve mentioned in the past, the Affordable Care Act of 2012 requires most health insurance companies to cover “breastfeeding support, supplies and counseling” in conjunction with each birth. This means that most insurance companies should cover a home visit from an IBCLC– though due to a gnarly licensing loophole, most private practice IBCLCs are out-of-network providers.
Unfortunately, this means that (unless you’re an Aetna subscriber) I can’t just take your insurance card when I arrive at your house and then bill your insurance carrier for my services. All my other clients have to pay me directly and then submit my receipt/superbill for reimbursement from their insurance company.
Trust me- I know that this is a giant pain in the butt, particularly considering you probably have a baby at home and have a million other things to spend your time on. I give every client a superbill, but I often hear that families never even bother to submit it for reimbursement because their insurance company makes the process too complicated.
But you really, really SHOULD submit for reimbursement for my services. Why?
Because you’re paying for it and you have the right to get that money back.
In the U.S. we tend to think of health insurance as something that we’re required to pay into- like taxes. We don’t really think about how much money we pay for insurance and then how much money we “get” from the company- how much money the company actually pays out for our care each year.
Health insurance doesn't cover ANYTHING for free- you're paying for all of it!
You should get your money’s worth and take advantage of anything that your insurance will cover, even if it means jumping through hoops.
The other reason I encourage you to submit for reimbursement isn’t fact-based… it’s related to my own cynicism about how the health insurance industry operates in this country.
I can’t help but believe that insurance companies are banking on the fact that many families won’t actually go through with submitting for reimbursement for out-of-network providers.
Any time a health insurance company makes you jump through a hoop to get coverage, they know it’s likely you just won’t bother. And if nobody submits for reimbursement for private practice IBCLCs, the insurance company doesn’t need to pay attention to how many of their clients are getting breastfeeding support.
They can get away with saying they cover breastfeeding support, but not actually ever paying for it.
They can pretend that families don’t need this kind of help, and that it’s not something their policies should cover- in the end, that hurts every nursing family and every nursing baby.
exactly how to get reimbursed for an IBCLC home visit, in plain English
Let’s talk about exactly how to submit for reimbursement. Every health insurance company is different so you should ALWAYS to call the member services phone number on the back of your insurance card before you book a home visit.
When you get a human on the phone, ask them:
- what your policy covers for breastfeeding support and counseling
- if they require you to see someone in-network, and if so, exactly who your in-network options are
- if you have no in-network options, or they can’t give you a list of providers, ask them how much money they will reimburse you for obtaining breastfeeding support and counseling from an out-of-network provider
- exactly what their procedure is for submitting for reimbursement after seeing an out-of-network provider
I’ve heard from my clients that some health insurance companies (like Harvard Pilgrim, Tufts, Fallon, and Blue Cross Blue Shield in Massachusetts) are great about reimbursing for IBCLC home visits, while other companies (*cough* United Health Care and Cigna *cough*) seem to automatically deny the first claim.
I’ve even heard that certain companies make patients resubmit the claim 4 times before they’ll reimburse for the services.
Please, don't give up! If your insurance company told you they will cover breastfeeding support and counseling, they need to do so.
If they deny your initial claim for reimbursement, call Member Services again and ask them where to send an appeal. Ask them if you need an appeal form that they provide you.
The National Women’s Law Center has a Breastfeeding Toolkit you can download that includes a step-by-step guide for drafting an appeal letter to send to your insurance company with your superbill/receipt. If you have any problems or questions during this process, you can call the National Women’s Law Service directly at 1-866-PILL4US or email them at firstname.lastname@example.org.
If you’re in Massachusetts and your reimbursement is denied, please PLEASE either file a Health Care Complaint with the Massachusetts Attorney General and/or file a complaint with the Massachusetts Division of Insurance. You can do both!
If your health insurance plan is one of the few that isn’t required to cover breastfeeding support and counseling, or you’re not interested in submitting for reimbursement, you should be aware that home visits from an IBCLC are eligible Health Savings Account (HSA) expenses. If you have a HSA through your work or your insurance company, you can use your superbill to submit for reimbursement from your HSA funds- you may even be able to use your HSA debit card to pay for the visit.
If none of these options work for you, then there should be free breastfeeding support groups in your area like La Leche League, Boston Nursing Mothers’ Council and Baby Cafes. All of these are staffed by educated breastfeeding helpers and can provide support to nursing families, although they’re not equipped to handle more complicated situations.
Remember, you’re paying for your health insurance coverage and most insurance companies are required to cover breastfeeding support, supplies and counseling. You have a right to be reimbursed for these services if your insurance company covers them. Do not let all the rigamarole and tomfoolery keep you from getting your money back– there’s no need for you to pay for my services twice.
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Can I ask how you became a in-network provider for an insurance company? Thanks!
Can you describe your experience becoming an in-network IBCLC for Aetna, please.
Hello how can i get a super bill so that my parents can seek reimbursement? Do you have a guide where we can create one?
My insurance (Anthem Blue Cross) has denied my appeal for reimbursement because they claim that my IBCLC Lactation Consultant is a non payable provider. They claim she doesn’t have the correct licence. Have you had any experience with this denial?
Most states don’t license IBLCCs so they’re taking advantage of the loophole I mentioned above. I’d send them the letter by the National Women’s Law Center (linked in the article above) with your claim resubmission.
I actually included that letter in my initial claim and they still denied it. I get the feeling that I’m not going to win this one. Do you have any other suggestion?
Hi Rachel! This is an amazing article, thank you! I am very interested in working with a lactation consultant to help me with the weaning process. However, I called my insurance company (Blue Benefit – an independent licensee of BCBS) and they told me they only reimburse for lactation support during pregnancy and up to 6 weeks postpartum. I am 12 months postpartum. Is this legal under the Affordable Healthcare Act? Is there anything I can do?
Good question Mallory! I believe the ACA says they’re supposed to cover you “for the duration of breastfeeding”, not an arbitrary number of months. Hope this helps! https://nwlc.org/wp-content/uploads/2015/08/nwlc_breastfeedingfactsheet.pdf
I know this may be a complex question but what can I expect with a price range for reimbursement for lactation services. I would be in a clinic setting.
There’s just no good way for me to answer this! Are you a parent getting the services done or are you a provider looking to bill insurance directly? There are a million variables from state to state and insurance to insurance. I can tell you that many of my clients get fully reimbursed by their health insurance companies- but some don’t get anything back at all.
Hello Rachel! I am an IBCLC just starting up my private business. Can I ask where you got your superbill? I am looking to get one for my consults and am in need of some direction. Thank you in advance!
I have the same question 🙂
Thank you for speaking up since I totally missed this question! http://dianawest.com/superbills/
I’m so sorry I missed this! I bought my Superbill (and actually all of my lactation forms) through Diana West. I love them and highly recommend her forms. http://dianawest.com/superbills/
Rachel,I would love to post this on my business Facebook page with all credits to you. May I?
Hi Gale! I’m flattered! Please feel free to share any of my posts as long as they are attributed to me and linked back to the original page 🙂
It’s a very complete, well written article – posting on my Facebook business page now! Thanks
Wonderful article! But your link to Baby Cafes is to the UK website. Please edit it to Babycafeusa.org
This is for listings of all the US Baby Cafes
Thanks, Lucia! I’ve updated the link to the USA “Find a Baby Cafe” page.
This is such a hot topic right now. I hope through the push for licensure for IBCLCs that insurance companies start covering home visit IBCLCs. It’s so important that mothers be able to have access to the care they need-especially in their own home where they’re comfortable.
Has anyone heard of Cigna reimbursing for claims? I just called and it seems that across the board, unless the lactation support happens at the hospital or a postpartum visit, they won’t cover it. So i’m not sure whether it’s worth submitting the claims or not?…
Tricare is covering lactation (up to 6 hours per baby). The process is straightforward – all electronic, straight into your business account. And they have just extended maternity leave to 12 weeks! Yeah to benefits for our military families!
The client may be able to get in-network reimbursement even if the IBCLC is out-of-network. My policy includes this verbiage “Any reduction in benefits or additional per hospital admission Deductible applied to charges of a Non-PPO Provider
will be waived if it can be shown that non-Preferred Provider care was needed either for practical or for medically
necessary reasons, as determined by the Plan Supervisor. Some, but not all, of such reasons are: • No Preferred Provider was within fifty (50) miles of the residence of the Covered Person;
• Medically necessary care is not available from a Preferred Provider;
I’m not sure if there was more to this comment that didn’t come through, but it’d be great if an insurer did this.
Not really. The other conditions aren’t applicable such as an emergency while away from home. It’s something you can let your clients know to ask about.