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Model Payer Policy for the United States – Steps to Make a Difference

by Cathy Carothers, IBCLC, FILCA, Chair of the United States Breastfeeding Committee

usbcIn the rapidly-changing landscape of insurance coverage requirements rolling out under the U.S. Affordable Care Act (ACA), few have been more confusing than those to cover “breastfeeding support, supplies, and counseling.” The lack of guidelines or recommendations as to who may provide and be paid for lactation care, and what kinds of equipment should be covered for breastfeeding families, has, frankly, created chaos for families, health care professionals, and insurance payers. Inappropriate breast pumps are being issued (ex: manual pumps for mothers pumping for a sick or preterm infant), pumps are often delayed (sometimes for up to 2 weeks) or limited to insurance company durable medical equipment providers, and professional support is often limited strictly to those already in the insurance company’s provider network … who may not necessarily be qualified in lactation support.

In response, the United States Breastfeeding Committee (USBC) has released a new, evidence-based model policy identifying best practices for payers that appropriately meet the requirements of the ACA and ensure adequate delivery of support for breastfeeding. The USBC worked collaboratively with the National Breastfeeding Center (NBfC), an organization with particular expertise in working with insurance companies, the California WIC Association, and other national entities, to develop the Model Policy: Payer Coverage of Breastfeeding Support and Counseling Services, Pumps and Supplies. In addition to support and counseling services and supplies/equipment, coverage of donor human milk is also included.

The process has not been easy! There were many considerations, including the rights of breastfeeding families to optimal care and the complexities of the breastfeeding community and its multiple types of care providers. This landscape was further complicated by the intricate nature of how insurance companies perceive goods and services and process reimbursements. In order to be recognized as a credible and useful resource by payers, the document was designed to offer solutions that would be palatable to them.

We believe this model payer policy is a significant first step in increasing awareness among private insurance companies concerning appropriate coverage for lactation goods, services, and donor milk. Here’s what you as IBCLCs should know about it:

  • Insurance companies have very strict guidelines, and licensure is their primary and historic criteria for “permitted providers” entitled to be paid under a policy. Although IBCLCs are not currently licensed in any state in the U.S., the GOOD news is that some payers DO also consider credentialing through an independent accreditation process (such as that used by the National Commission for Certifying Agencies). Therefore, language was included to demonstrate that IBCLCs are one example of a provider who does meet that standard. Aetna has already taken the step of including IBCLCs among their contract providers whose services are covered, and hopefully many other companies will follow their example.
  • The model payer policy uses the term “approved lactation care providers” as one of the types of recommended permitted providers, with a footnote explaining that term. IBCLCs meet the document’s definition of an “approved lactation care provider” because they “have individual certification awarded by an independently-accredited program that measures assessment of predetermined standards for knowledge, skills, or competencies in a health-related profession…”
  • “Approved lactation care providers” are listed as one of the types of recommended permitted providers for each type of breastfeeding support and counseling services in the chart on page 8. This means that IBCLCs in private practice, as well as those working in other health care settings, are recommended as permitted providers. “Approved lactation care providers” are also listed as one of the types of recommended permitted providers of breastfeeding pumps and supplies in the chart on pages 9-10.
  • Unfortunately, the ACA requirement of coverage of “breastfeeding support, supplies, and counseling” only applies to private health plans. It does not apply to Medicaid; rather, coverage decisions for Medicaid are managed at the state level. In 2012, the Centers for Medicare & Medicaid Services (CMS) published an Issue Brief about “Medicaid Coverage of Lactation Services.” The brief encourages states to go beyond current requirements to include lactation services as separately reimbursed pregnancy-related services, and provides examples of current state practices. We encourage you to work with your state United States Lactation Consultant Association (USLCA) chapter and/or state breastfeeding coalition to advocate for the implementation of the model payer policy’s recommendations in your state Medicaid program. The USBC is also committed to using the model payer policy to advocate for changes in the federal Medicaid statute and regulations.

The coverage details listed in the Model Policy are merely recommendations. The reality is that individual insurance companies may continue to implement the required coverage of “breastfeeding support, supplies, and counseling” however they wish, and some may insist on only using their existing network of providers. This is why continued advocacy will make the difference! The USLCA is your primary mechanism for advocating for the IBCLC in the U.S., so we urge you to get involved!

Navigating the landscape of private and public payers is indeed complex. As clinicians, we have a lot to learn to fully understand their language and policies, as well as to be the levers to influence change. Be watching for a series of webinars from USBC/NBfC soon on how we can do just that.

What’s exciting is that national attention to breastfeeding has never been higher in the U.S. And what happens in the U.S. can have a profound impact on global policies and practices, as well. By working together, we can build on this amazing momentum and make a difference for all new families.

Cathy Carothers_2012Cathy Carothers is co-director of EVERY MOTHER, INC., a nonprofit organization providing counseling and lactation training for health professionals across the United States. She is the current Chair of the United States Breastfeeding Committee, and immediate past president of the International Lactation Consultant Association. She was recently named a Fellow of ILCA, and has been an International Board CertifiedLactation Consultant since 1996.

An experienced trainer and speaker, Cathy has provided more than 400 training events in every U.S. State and Territory, and several foreign countries. She is the project director for national breastfeeding programs for the Federal government, including the brand new breastfeeding peer counseling program for the USDA WIC Program, Loving Support Through Peer Counseling: A Journey Together, and the national WIC staff curriculum in breastfeeding, Using Loving Support to Grow and Glow in WIC. She is also author and project director for the national Business Case for Breastfeeding project through the U.S. Department of Health and Human Services and is involved in national level outreach to business organizations and labor unions through the HHS Office on Women’s Health.

A former University public relations director, she served as the State Breastfeeding Coordinator for the Mississippi WIC Program, coordinating the state’s comprehensive peer counseling program and breastfeeding promotion campaign that earned them the

Cathy is married to a United Methodist minister, and is the mother of 5 healthy breastfed children, now ages 20 to 32. She is also the proud grandmother to two beautiful breastfed grandsons, ages 3 and 1.


Thank You, Cathy Carothers!

As the 2012 ILCA Conference has come to a close, one of the things that was expressed time and time again was the gratitude towards our leadership for bringing the advocacy fo breastfeeding and especially the IBCLC profession into this exciting era of breastfeeding promotion. Cathy Carothers has served as our president during this time and, as she passes the gavel to Liz Brooks, we want to take a moment to express our thanks to Cathy for her term as President of ILCA.

We caught up with Cathy during the conference and here’s what she had to say about her service:

1. How did you first get involved with ILCA in a volunteer capacity? What jobs have you held before becoming president?

That’s an interesting story!  My professional background is in the field of marketing/public relations, and I got excited about the lactation “profession” when a WIC nutritionist asked me to consider becoming a peer counselor when I was pregnant with my 5th child.  I had loved breastfeeding and believed in it passionately, and once I became a peer counselor helping mothers and babies, I was convinced, in my naiveté, that I wanted to someday save the world for breastfeeding families.  I set my sights on becoming an IBCLC and immediately joined ILCA back in the early 1990’s.  But it wasn’t until someone on the ILCA Board asked me to consider running for a board position (the new position of Director of Marketing in 2003) that I realized I had gifts that could contribute to my professional association, as well.  And what an incredible ride it has been!  If only I had known how rewarding service to ILCA could be, I would have gotten involved much sooner!

2. What has been your most fulfilling accomplishment as president? Your most challenging?

Without question, my most fulfilling accomplishment as President of ILCA was watching ILCA’s  most comprehensive and bold strategic plan ever unfold (Editor’s Note: Look for an upcoming blog post about this exciting plan!).  But it wasn’t MY accomplishment at all…it was based on the constructive suggestions of over a thousand ILCA members and global stakeholders who took the time to tell us what matters most to them, and a group of smart, passionate board members who weren’t afraid to say YES to our most important calling: to promote the IBCLC credential.  The challenges over the years have been so minimal they’re hardly worth mentioning…keeping monthly calls to an hour when everyone is so excited about the incredible momentum building, keeping time zones straight when working with an international board, and remembering to bring chocolate for meetings.

Cathy and her husband, Davis.

When I look into my ILCA crystal ball, I see an incredible vision of IBCLCs in every hospital and birthing facility, valued and respected for the expertise they provide.  I see universities with quality lactation programs integrated into their curricula, and global policy makers relying on IBCLCs in  international forums.  I see IBCLCs who are connected and confident as skilled professionals, and mentoring the next generation of IBCLCs.  I see an explosion of lactation research that not only forms our foundation of evidence-based practice, but is accessible and USED by all health professionals and policy makers.  I see professional education available in languages that people speak and accessible to the far corners of the world.  And I see that EVERY ILCA member is a part of that vision.  Can I just say it?  ILCA truly IS YOU!

Cathy, we thank you and appreciate the leadership you have provided!


New Possibilities in 2012! A message from our President

Beginning a new year can be a rejuvenating time to set new goals and explore new opportunities.  For the International Lactation Consultant Association, the opportunities have never been greater!  I hope each of you will resolve TODAY to get involved in your professional association.  You’ll find, as countless others have, that giving your time and your talents will come back to you in the most incredible ways as you seek to make a difference.

Earlier this week I sent my ILCA President letter to inform you about the status of ILCA as we begin this new year.   Click here to read about ILCA’s strong foundation of sound financial health and highest membership numbers ever (over 6,000!), and details about the many exciting new initiatives.

Coming in 2012:

  • The 2012 ILCA Conference in Orlando…with live simultaneous translations in Spanish for the first time ever, a new ILCA “lounge” for networking with colleagues, and family activities to make this a wonderful vacation while you learn.  Be sure to check out the YouTube™ video at and pass it along to your colleagues on your Facebook™ and Twitter™ sites and be an early bird registering and have an opportunity to win a fabulous i pad 2, check the details.
  • New changes to the Journal of Human Lactation under the new editorial leadership of Anne Merewood.
  • CERPS on Demand© with a full slate of webinars in many languages!
  • Baby-Friendly Initiative Committee to explore strategies for promoting and implementing BFHI worldwide.
  • European Task Force to address member needs across Europe.
  • Continued expansion of our robust translation program.
  • Collaborative projects with IBLCE, including a NEW consumer website, IBCLC promotional brochure, and hospital outreach initiatives.
  • Position papers and clinical protocols.
  • NEW edition to the Core Curriculum for Lactation Consultant Practice.
  • Expansion of our global relationships worldwide.
  • And more!

I love to sign my communications, “ILCA is YOU,” and I believe that phrase perfectly captures how important each of you are to ILCA’s success.  There has never been a better time to get involved, so join us in 2012 as we work together to meet the needs of the lactation community worldwide.

Cathy Carothers, BLA, IBCLC, FILCA ILCA President 2010-2012


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