The Case for Creating a Model Insurance Policy: Payer Coverage of Breastfeeding Counseling Services,Pumps,and Supplies

Introduction

Healthcare insurance companies (also known as “payers”) have had to make many fundamental changes to the services that they cover since the implementation of the Affordable Care Act of 2010. Many pieces of the Act were designed to be phased in from signing of the law through January 1, 2014. Effective August 1, 2012, under the provisions of Women's Preventive Health Services, comprehensive lactation support was implemented, and payers had to begin covering breastfeeding and lactation support, equipment, and services for new and non-grandfathered health plans.

The new law states that payers must cover, at no cost to the patient, “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” This statement leaves the specifics of coverage undefined: What is “comprehensive lactation support”? Who qualifies as a “trained provider”? Why only cover costs for “renting” equipment?

From the payers' perspectives, the new provision has created confusion as well as an opportunity either to embrace the spirit in which this provision has been enacted or to fly as close to the line as possible by providing as little coverage as legally allowed. Most insurers are for-profit companies. As such, their decisions are based primarily on economic factors. With the lack of clear directives for coverage, a lack of knowledge about breastfeeding services and equipment necessary for breastfeeding support, and an undefined “need” for access to these services from the marketplace, many insurers have been left to guess what benefits to actually provide.

Current Coverage

Currently, about 20% of payers in the contiguous United States (determined from a pool of the 71 major insurance companies operating in the contiguous United States, represented in The Verden Group's Payer Policy database [www.theverdengroup.com]) have published written policies identifying coverage for breastfeeding services and equipment. These policies vary greatly, with some payers covering only minimal equipment and no specialized providers, to a few insurers that seem to have fully embraced it with significant support, which is the purpose of this most fundamental of preventive care benefits.

For example, nationally, Aetna decided to substantially cover lactation consulting services and provide coverage for multiuser double electric pumps for mothers who wish to breastfeed. However, Aetna also took the innovative step of opening its network to lactation consultants that have obtained the International Board Certified Lactation Consultant (IBCLC) designation from the International Board of Lactation Consultant Examiners^® (IBLCE^®), an independent international certification body, which has been continuously accredited by the National Commission for Certifying Agencies since 1998. These providers are credentialed by Aetna and contracted into the network the same way as Aetna credentials and contracts licensed providers.

This addition of IBCLCs to Aetna's network is particularly impressive because of the complexity involved in recognizing a professional standard of care for lactation care providers. Lactation care providers vary in their training, licensure, certification, level of care, and ability to deliver care. In order to credential providers for addition to a payer's network, standards must be met against which the provider is measured. Although there are clearly defined credentialing standards for most licensed providers published by the National Committee for Quality Assurance, this is not the case for lactation care providers. This required finding an independent accrediting body that recognized a specific standard of care for lactation care providers and then contract those certified individuals into their provider network.

In addition to expanding access to well-qualified lactation consultants, Aetna also covers a reasonable number of visits. Furthermore, Aetna clearly states what billing codes should be used for breastfeeding services and equipment and identifies coverage criteria.

Many other payers that are covering services are doing so only through their existing network of providers. This raises concern, as for most of these payers, there is no requirement for network providers to have any formal training or education in breastfeeding medicine, education, or support. It is difficult to deliver improvement in population health in this area when providers are not equipped to successfully address the issues that contribute to early weaning or an inability to initiate breastfeeding. For example, although United Healthcare also covers multiuser double electric pumps for nursing mothers and allows those pumps to be supplied directly by in-network providers as well as durable medical equipment companies, in many cases it restricts services by limiting coverage to licensed providers only (e.g., MD, DO, advanced registered nurse practitioner, etc.) and with no known breastfeeding medicine qualifications or certifications required.

Many more payers are doing as little as possible to deliver on the potential for improving population health. These payers cover only a manual breast pump, have no published policies on coverage, and have failed to educate their staff that coverage of lactation services is now mandatory. As a result, many patients being told that this is not a covered benefit.

By investigating the policies payers have published, canvassing lactation consultants in the marketplace, and speaking with the insurance companies directly, it is clear that payers are in great need of education and assistance with regard to understanding the role of breastfeeding in improving population health as well as needing assistance in developing comprehensive lactation and breastfeeding care coverage. The National Breastfeeding Center set out to assist payers in the following ways: providing clarification of what is needed, supported by clinical evidence; presentation of a comprehensive policy detailing how, when, and why to provide benefits; guidance on coverage criteria, provider types, coding, and equipment presented as a comprehensive policy for wholesale adoption; and engagement through a public score card that provides an invitation to be consistent across the industry.

A Model Policy

The first step to end payer confusion—and the marketplace chaos being reported from patients and consultants alike—is the creation of a “model” payer policy for covering breastfeeding counseling services, pumps, and equipment. This model was developed and co-branded through a joint effort between the National Breastfeeding Center and the United States Breastfeeding Committee. Written directly for insurance companies, in a format most payers will recognize as very similar to their own, the model policy (available at www.nbfcenter.com) provides the background on breastfeeding and lactation care services and outlines provisions for supporting breastfeeding at a substantive level by providing appropriate coverage for services, pumps, and supplies, as well as for human donor milk in cases of medical necessity.

The model is designed to provide a roadmap for payers to understand: the importance of infants being fed human milk in order to impact the overall health of the public, as a public health initiative; how to substantially support breastfeeding efforts through the provision of adequate benefits in order to effectively deliver on population health improvement; and that all pumps are not equally efficacious, and therefore coverage should only be for those pumps that meet or exceed certain recognized standards.

Our hope is that payers will adopt this model policy, wholesale, across the country. For those that do not, better education will reveal what aspects of their benefit coverage are weak, and better-informed decisions can be made for coverage in the near future.

Further Action

However comprehensive, just providing a model policy for coverage for breastfeeding services and equipment is unlikely to be enough to garner significant change at the payer level. Therefore, the National Breastfeeding Center is undertaking a national initiative to bring about transparency, better education, and accountability for coverage.

Utilizing The Verden Group's Payer Policy Search tool to research 71 major payers in the contiguous United States, as well as manually researching each of those payers' Web sites for related information, the National Breastfeeding Center has catalogued all published policies on this subject (as of July 31, 2013). Any payers with published information regarding breastfeeding services and pump coverage are “scored” according to certain criteria to determine which payers are effectively supporting breastfeeding through benefits and which are not (score card can be found at www.nbfcenter.com).

As most payers today are for-profit entities, change usually only comes about in four ways: through economic incentives, regulation, market demand, or publicity. By publicly ranking payers based on their policies, this creates transparency across the industry and helps to encourage change.

Payers' published information has been graded on the following criteria: appropriateness of coverage levels for services and equipment; criteria for coverage of services and equipment; accessibility to qualified providers; and pump choice and ease of access to them.

The Path Forward

Our intent is to educate payers on the need to cover breastfeeding services and equipment appropriately, through the use of the model policy, and to hold each accountable for the coverage it provides through the score card initiative. In doing so, we believe that breastfeeding will be better supported by the very organizations that are responsible for access to, and the delivery of, healthcare services and create consistency in benefits across payers and across the country.