If you’ve done any research into pregnancy or breastfeeding in the United States in the past few years, it’s likely you’re aware that the Affordable Care Act expanded preventative health care services to include breastfeeding support- as of August 1, 2012, health plans in the United States were generally required to cover “breastfeeding support, supplies and counseling” in conjunction with each birth.
In the summer of 2012 I was already on pathway 2 to becoming an IBCLC (International Board Certified Lactation Consultant) and I was beyond thrilled to learn that insurance companies would be paying for my services.
So many barriers to proper care would be removed!
Families could get the help they needed from me and other IBCLCs without having to pay out of pocket!
It was about damn time!
Yet here I sit, five years later, and very little has changed on the insurance front for private-practice IBCLCs.
Clients ask me if their insurance covers my services, and I have to shrug my shoulders and explain that I am only in network for one insurance plan- Aetna. Most IBCLCs have cobbled together a workaround- we take our client’s payment and provide them with a superbill that can be submitted to insurance for reimbursement.
I can never guarantee my clients that their insurance company will reimburse them- even though the wording in the ACA’s Women’s Preventive Care Guidelines state that health insurance should cover “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.”
Confused? Wondering how the insurance companies get away with not covering lactation support and counseling by a trained provider like an IBCLC when it’s stated as a requirement by the U.S. Department of Health & Human Services?
You’re not the only one.
There is a puzzle piece missing in this picture, and it has led to what seems like a gaping loophole in the insurance companies’ coverage of the services I provide.
That missing puzzle piece is licensure.
IBCLCs are not licensed providers in 47 of the 50 states.
Only Rhode Island currently licenses IBCLCs– Georgia and Oregon are getting licensure set up now- and the majority of insurance companies will only contract with licensed providers.
Yes, there are some OBs, Nurse Practitioners, Pediatricians, etc. who are already licensed healthcare providers AND are also IBCLCs- they do provide lactation support to their patients (and that is a wonderful, wonderful thing).
But there are currently NO licensed lactation support providers- no one who is licensed SOLELY for the practice of providing “comprehensive lactation support and counseling”.
Anywhere (other than Rhode Island and soon, Georgia and Oregon).
They don’t exist.
Can you see the loophole now? Basically the (highly technical, super classy) way I see it is this:
ACA: Hey insurance companies, y’all have to cover lactation support! It’s important!
Insurance companies: Cool, ACA, happy to do that. We’ll pay for breastfeeding support from licensed IBCLCs, ’cause as you know, we only pay licensed peeps.
ACA: But… there’s no licensure for lactation consultants.
Insurance companies: Not our problem.
ACA: …not our problem either.
Insurance companies: Peace out!
As an IBCLC in private practice, I am very supportive of well-defined licensure for IBCLCs.
As I mentioned in a previous blog post, currently anyone can call themselves a “lactation consultant.” Licensure is viewed as a way to protect the public from potential harm; in healthcare, licensure certifies that the licensed individual has earned the minimum education and experience required to practice, and a licensed healthcare provider has to prove ongoing knowledge and skills in the field to stay licensed.
According to the United States Lactation Consultant Association, licensure therefore could be used to protect the title of lactation consultant, provide a single set of standards for the profession enable, autonomy of practice and increase access to care, culminating in support for billing and reimbursement.
In my eyes well-written licensure bills for IBCLCs are a win-win situation. Families get the lactation support and counseling that they need, IBCLCs are held to a high standard of education and care, and families don’t have to pay out of pocket for preventive services.
Yes, I will have to pay licensing fees.
Fine by me.
WORTH IT.
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There is no process for national licensure, so each state licenses it’s own healthcare professionals. Currently 36 states have a group of people working on licensure initiatives for IBCLCs. In Massachusetts, where I live, House Bill H1151 is making it’s way through the legislature. It’s getting there, slowly… I hope. I’m doing what I can to help it along the way.
You can help, too, by signing the petition to support Licensure for IBCLCs in Massachusetts.
What can you do to get my lactation services covered for your family in Massachusetts?
You can mail in that superbill I provide you at the end of our session, and if you are denied reimbursement, appeal. The National Women’s Law Center has put together a toolkit to help families understand their breastfeeding coverage and to help file appeals.
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!
And consider contacting your state and federal representatives and telling them that IBCLCs need licensure.
After all, 70,000+ babies are born in Massachusetts every year- almost 4,000,000 in the entire United States every year- and each and every one of them deserves skilled lactation care. On behalf of them, I thank you.
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26 thoughts on “Why most private practice IBCLCs don’t take insurance”
Hi! I’m a RN, IBCLC. Because I also hold a RN license, would insurance be more likely to provide reimbursement? And do I have to have a LLC company set up in order for me to provide my clients with a superbill? Could you email me a copy of a superbill? I’m still very early in my adventure to setting up prenatal breastfeeding education, so any help/advice is appreciated. Thanks!
Hi Sara! Most of these questions are too complicated for blog comments, but you can purchase a superbill through Diana West or Pat Lindsay, they both sell forms made just for IBCLCs.
I propose that Baby-Friendly hospitals alter their services to include two home visits with RN/IBCLCs. Using registered nurses could potentially fix the insurance coverage problems and the additional home-visits will aid in increasing exclusive breastfeeding rates and duration thus improving the health of mothers and infants until the states are able to provide licensure to IBCLCs. This is necessary because there is a drastic drop in breastfeeding rates after hospital discharge to 3 and 6 months postpartum. According to the 2016 CDC Breastfeeding Report Card, in the United States 81% of infants were ever breastfed, but only 44.4% were exclusively breastfeed at 3 months and 22.3% at 6 months (CDC, 2016). The drop in breastfeeding rates needs to be addressed and that starts with mothers having access to cost-covered lactation support. Still addressing Baby-Friendly hospitals, I would make changes to two of the Baby-Friendly Steps. Step 5 states “Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants,” however the change I would initiate would be for an IBCLC will meet with the mother while in the hospital to show the mother how to breastfeed and maintain lactation (Baby-Friendly USA, 2016). Step 10 states “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center,” however that is not working because of insurance issues and a clear drop in exclusive breastfeeding rates from hospital discharge (Baby-Friendly USA, 2016). I would change that so hospitals are required to provide a minimum of two optional home-visits with the IBCLC the mother established a relationship with and ensure there is an IBCLC available at all infant check-ups. This would be an initial step at ensuring many mothers receive the lactation support they need, while waiting for states to enable licensure for IBCLCs so that all mothers whether or not they gave birth in a baby-friendly hospital have access to lactation support.
Can anyone explain a superbill? I know it will require an NPI and EIN number and other information but why are moms not getting reimbursed even with a superbill ? I know some businesses who use it and have success. Is it just a matter of the insurers choosing to reimburse some and not others?
Hi Kesha! A superbill is basically a fancy receipt that lists the appropriate procedure and diagnosis codes for whatever services are performed. Insurance companies are notoriously picky about which codes they will and won’t reimburse for so it tends to be a crapshoot for these families to get reimbursed… and they often give up rather than spending the newborn period fighting with their insurance company.
Another important part of this conversation should be about what kind of reimbursement we are talking about. Some have reimbursed, but the amount is quite different from companies and state to state and plan to plan. So, even if we were contracted with insurance companies, our payment may very well be way under what the services we provide would typically cost.
As a I understand it the ACA covers “other health care professionls” to include lactation services. Is anyone familar with Medicaid reimbursement? Ir does this vary state to state? Has anyone had any success billing for insurance outside the major insurance providers?
Rachel, I love your post, I completely agree with needing licensure but since 2012 Aetna and some Blue Cross have been enrolling non rn ibclcs as in-network providers. There are only a few hundred across the US and about 25 are here in PA. It’s a crazy game. Also a GAP exception is another way to help gets moms paid. But licensure is key, then we can have ascent at the big kids table!
Donna, thank you so much for all your expertise in helping IBCLCs navigate insurance-land! I wish BCBS was credentialing IBCLCs here in Massachusetts. I am very optimistic that all of our work on licensure will pay off soon.
My understanding is the major drawback to licensure would be if the states then require malpractice insurance (as they do for other licensed medical practitioners). Then becoming a licensed LC would be insanely expensive as it is right now in most states for midwives to obtain licensure (aka, insurance).
IBCLC malpractice insurance is $100 a year. Many of my friends who are IBCLCs have it and they are not nurses or doctors. It is something we have as practicing IBCLCs regardless and it is not costly. It really doesn’t matter b/c with the state of things now we can’t really work. Better to work and have an expense than not work in our chosen area at all and help moms and babies.
Can you let know name of company that provide IBCLC malpractice insurance? been looking for one.
thanks
I hope you found it by now, but if you didn’t it’s https://www.cmfgroup.com/lactation-consultant-ibclc/
Most private-practice IBCLCs already have malpractice insurance (and if they don’t, they really should). Right now our polices aren’t too expensive if we’re *just* an IBCLC, but I know the price rises significantly if you’re an IBCLC and also a CNM (midwife), for example.
This is my 5th year as an IBCLC, in the beginning I was very excited to be apart of the lactation journey for women. I still am, however the opportunities are just not there unless you are an RN (I’m an LPN), licensure, insurance companies etc… I do have a private practice and love being an LC, but if I do not find a worth-while means to use this certification before the 10y mark, I will not be renewing. More money and time has been invested into being an LC than the opportunities to use it. I love every encounter with a new or seasoned mom, the outcomes are positive and my heart soars with happiness; the opportunities are just not there. I pray for a break in the clouds someday. Good luck to everyone.
Stephanie, there are many opportunities out there for you to use your knowledge and skill. IBCLCs play many roles within the health care team. Get connected to the closest USLCA chapter. Connect with other IBCLCs! There is so much work to be done but there are few hands so reach out…….
But, as the title states, and the requirements are for continuing to call yourself an IBCLC is that it is internationally board certified. I know that that doesn’t equal licensure, but that should meet state board requirements to create licensure without having more test or paperwork submitted, except you initial certification and then the required continuing education. You would think the states, with the push of the Feds, would want this done so that help can be made to women and babies to increase the goal of 2020 for breastfeeding national rates! Get it together state boards!!!
Excellently put together! I am working with a colleague and friend of mine to begin a Northern California USLCA chapter in an effort to further IBCLC licensure in California. We’re in this together!
Can I join you in this effort? I live in San Diego and I am and RN, IBCLC looking to start a PP.
There ARE licensed lactation providers outside of Rhode Island. Physicians, PAs, nurses, nurse practitioners and other licensed health care providers that provide lactation care exist in every state. You should stick with saying that no state except Rhode Island currently licenses IBCLCs but the above practitioners may have their IBCLC as well and be reimbursed for their services. There is still a lot of work to do though.
I am an RN with a license. I am also an IBCLC. As an example, BCBS will not accept my application to be an in-network provider of lactation services because I am not licensed as an IBCLC. So, my clients submit their superbills once, get denied, get frustrated or busy, don’t re-submit, and don’t get reimbursed.
Well that’s oxymoron if I ever heard one!
She stated that many IBCLCs are practicing but clarified that they are licensed as nurses or physicians etc. It is by virtue of that education/training that they hold a license; they do not hold a license as an IBCLC. I am an IBCLC and not a nurse or doctor and therefore I cannot become a licensed provider with insurers. As an update to the article Georgia just passed licensure for IBCLCs. So now there are two states.
Hi Annie! I think we’re looking at a matter of semantics here. My understanding is that there are licensed healthcare providers who provide lactation support, but they are NOT licensed AS lactation support providers. There is certainly a difference, though of course if you are a parent who is lucky enough to see a provider who is already a licensed HCP AND an IBCLC, they will likely be an in-network provider for lactation services. I have heard of very few of these licensed HCPs that do private practice and accept insurance or are in-network providers other than for Aetna (which is not widely used here in Massachusetts).
Thank you. Very well said.
Thanks, Dawn!