Misinterpretation of the Affordable Care Act’s Directive for Payment for Lactation Support and Other ‘Trends’

We are deeply concerned to see the continuing misinterpretation of the Affordable Care Act’s guideline to cover breastfeeding services, most recently posted on HealthConnectOne.org’s site advertising a tweetfest on the topic ‘Breastfeeding Support – Who Gets Paid?’. On that page it states “The Affordable Care Act requires insurance companies to reimburse providers of breastfeeding support”.  But the ACA says no such thing. . .

So what does the ACA actually say?

Breastfeeding support, supplies, and counseling. Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment. In conjunction with each birth.

There is an enormous difference between requiring insurance companies to “reimburse providers of breastfeeding support” stated on the HealthConnect One site, and the actual law which states that “comprehensive lactation support and counseling, by a trained provider” needs to be a covered benefit.

Let’s examine the difference in the statements. The manner in which HealthConnect One’s statement is written could have people believing that ANYONE providing ANY support to a breastfeeding mom could be paid by an insurance company for that service.  We certainly do not disagree that breastfeeding support is a most valuable service and deserves to be financially supported; what we are concerned with is a statement that implies that insurance companies could pay anyone for that service.

Here’s the problem. Regulations prevent insurance companies from deciding who should get paid and who should not. It is not an arbitrary process. In order to be recognized as a “trained” provider, the usual standard is a medical license. In order to participate in an insurance company’s network of providers, you must go through a rigorous credentialing process, by regulation, standard and law. In order to ‘pass’ the credentialing process, you must have an identified credential.

So therein lies the problem. By suggesting that insurance companies are supposed to, by law, pay ANY provider of breastfeeding services, this is not only misinterpreting the law, it is also ignoring the regulations and standards under which insurance companies must operate. We are greatly concerned that a lack of care around stating precisely what the law mandates is misleading many providers of these valuable services into thinking that it is possible to be paid by insurance companies for their commendable work.

Further, with regard to there being “a trend in the breastfeeding community to recommend that ONLY licensed providers or individuals with credentials should  be permitted to receive reimbursement for lactation services”, we must correct that statement. What is completely overlooked is that insurance companies can ONLY pay professionals that have credentials and that is not a “trend”. It is a statement of fact.

Why can insurers only pay credential-carrying providers? Well, think about it this way. Without these credentialing standards, how would an insurance company determine who is a professional able to meet a defined standard of care? Would it be okay to list a doctor that simply says that they meet a standard of care but who doesn’t possess a medical license validating that they actually do? Of course not. In the same way, it is impossible for insurers to determine whether a person providing breastfeeding services is someone who simply read a book or is someone with years of experience, unless they have some third-party credential to indicate that they have achieved – or are recognized for – a standard of care in this regard.

So let’s get the record straight once and for all. The National Breastfeeding Center is supportive of everyone that supports and helps breastfeeding moms. Our role has been to identify what is POSSIBLE under the law, at this point, and in doing so, it has led some organizations – namely  @HealthConnctOne, @MomsRising and @Support_ROSE – to unwisely and falsely proclaim a “trend” to exclude some providers.

This is a basic fact – insurance companies cannot, rather than will not, pay for services provided by those that they cannot credential or identify as having achieved some standard of care. This simple realization should help to free up the enormous resources (time, energy and expense) that has been expended to date on chasing trends.

We sincerely hope that by understanding the nature under which commercial insurance company payments are currently made, and recognizing that insurance companies are only ONE source of support in providing these most necessary of services, these organizations will turn their resources toward helping their members achieve funding through many avenues – securing federal and state funding, attracting sponsorship or achieving credentialing standards that can help to get many providers the commercial payments sought that the ACA has helped to champion. At a time when the market is wide open for exploration, it is imperative that we see what is possible, what is doable under the law, and what other avenues of funding may be available for ALL types of support.

While we certainly do not speak for the insurance industry, we are happy to answer any insurance related questions that we can shed light upon and will continue to work toward achieving fairness in payment for professional services rendered under the law.

Most sincerely,

Susanne Madden

COO, National Breastfeeding Center


5 thoughts on “Misinterpretation of the Affordable Care Act’s Directive for Payment for Lactation Support and Other ‘Trends’

  1. kasey says:

    I can not speak for any organization listed above, but it is my understanding that they are not trying to get just anyone paid for offering breastfeeding support, but rather they are trying to start a movement that will expand breastfeeding service to mothers of all ethnic, social and economic groups. As it stands right now very few are getting paid period. As a an IBCLC I can only bill in conjunction with another party, wouldn’t it be great if there was a network of tiered paid breastfeeding support professionals where peer counselors could work with IBCLCs. As you are probably aware the organizations listed above offer in depth breastfeeding support training and as someone who has went through an abbreviated version on their peer to peer support program they are the first to say “refer, refer, refer!”. It is in my opinion that your article is a little misleading and could possible damage the work they are doing to expand breastfeeding support to all mothers. We need to work together to help increase the pathways for reimbursement for these wonderful services. I feel you make some valid points but I also feel you have left out some very important facts. If I am missing something please email me so that I can be corrected

  2. Melinda Toumi says:

    This statement doesn’t reflect an accurate picture of insurance companies – which absolutely pay for blood draw services ( for which one may have only a certificate and NO medical or nursing license) same idea for CPMs or HHA etc. Why not IBCLCs? You’ve failed to mention the biggest problem : the amount doctors spend in getting reimbursed for services is ridiculous – no IBCLC alone would have the resources to deal with the medical billing. Insurance/ACA fail on breastfeeding support in my opinion.

  3. Leanne Jewell RN - BC IBCLC LCCE FACCE says:

    As a hospital based RN with IBCLC credential I tell my mom’s with private insurance to ask their medical p to video for a prescription for a pump and follow up with lactation for whatever I feel they need i.e. assessment of milk transference for excessive weight loss or idifficult latch. I tell them to contact their insurance provider to get their referrals for our community. I then give them the http://www.ilca.org website to contact a ibclc credentialed lactation consultant to cross reference. I explain the referral they receive from the provider may not be hospital based and they can see if referral is a credentialed professional. They need to let provider they need a credentialed professional. This act is a step in right direction but we need to advise patients this is available but they need to see to their need. I see many who know about the pumps most are getting PNS.

  4. Lafyjfk says:

    For the person castigating the article and comparing some lactation services to blood draw services – blood drawers don’t set up shop on the corner and offer to draw blood independently. They are employed by some agency and are not paid directly by the insurance company. They are responsible to the employer who verifies training and insures them. In addition to the credentialing process, there is a need for coding that identifies what level of care us provided for patients. Breastfeeding is a unique process involving at least two clients. Coding and billing definitions do not currently reflect the complexity and time involved in caring for these patients. Visits cannot be compressed into the insurance driven model of 4 patients per hour! A lot more work to be done to really make affordable, competent care available and effective.

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