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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.


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