If you’ve been frustrated or brought to tears by trying to get your insurance to cover a breast pump, you need to read this. Amy L., a mom who was trying to get a pump from her insurance company, only to be told they were offering only a manual pump, fought that provision and WON. Because she fought, all the moms who have her insurance plan are now being given double electric breast pumps. We asked her to write up her story and tell other moms how she did it. Number one, you’re not alone. Number two, it only takes one mom to bring about big change. Here’s her story:
It doesn’t take a lot to get me excited these days. Having my two-year-old and my six-month-old take a long enough nap for me to be able to shower, dry AND straighten my newly sort-of-wavy-but-not-in-a-good-way locks (thank you, pregnancy, for adding even more work to a mother’s day), and put on some makeup? It’s pretty much like winning the lottery. So last August, when I heard that the Affordable Care Act (ACA) would require breast pumps to be fully covered by insurance, I got pretty excited. I was VERY pregnant, and, while I had a breast pump I’d used with my older son (unfortunately NOT a Hygeia), it had started making odd noises that sounded as though it might at any moment decide it had had enough and send the milk blowing back out in my face. A nice, new pump at no additional cost to me would be one less thing I’d have to worry about buying.
I was nearing my September due date, so I contacted my insurance company to find out what I needed to do to get my new pump. I thought I might have a little difficulty getting to the bottom of the new coverage, but YOU HAVE NO IDEA. At first my insurance wouldn’t give me much information at all. Shocker, right? They confirmed that my policy was non-grandfathered (we’ll get to that in a minute), but they told me they weren’t able to discuss future coverage since the provisions of the ACA would not be included in my plan until it renewed on 1/1/13. Hmmm. I’m not very good at waiting around, and it sounded a lot more like they just didn’t have the answers, so I tried again. (Please, they should have known better than to try to discourage a 9-months-pregnant mom on a mission. I had to use all my channeled-up angst and discomfort for good, right?) The good news is that I finally spoke with a representative who had more information. The bad news is that her information was bad news: my insurance company had decided they were only going to provide manual pumps under the ACA.
I was mad (and the pregnancy hormones didn’t help). My very large insurance company offers me discounted gym memberships. They provide an 800 number where I can talk to a nurse for free. They have a whole program for expecting moms that includes a nurse calling me personally multiple times throughout my pregnancy. I’m pretty sure they even pay for Viagra. But what do they offer to moms who want to provide the best nutrition for their babies? A manual pump.
It’s well established that breastfeeding is extraordinarily beneficial for both baby and mom. Insurance companies should be willing to do everything they can to help moms who want to breastfeed! Providing expensive double-electric pumps with no cost-sharing to mothers who want to breastfeed? That’s a game-changer for women who want to breastfeed, need a pump, but can’t afford to purchase one. Providing a low-cost manual pump meant only for occasional use to mothers who want to breastfeed? Really, insurance company? You really think that that’s going to improve breastfeeding rates?
So, like I said, I was MAD. But I was also really, really uncomfortable with the combination of my late September due date approaching and the terribly hot summer I had endured, so I decided to wait a bit to see what happened. I tried to do my research, but because the provisions were so new there wasn’t a lot out there. I hoped things would change by the time my policy’s renewal date came around. I kept my fingers crossed that another angry pregnant woman whose renewal date was before mine would also get really mad and do all the dirty work for me.
No such luck. After I gave birth to my son in late September, I began using my old pump that grew angrier-sounding by the day. When January rolled around, the insurance company was still only covering manual pumps. It didn’t matter what I said, what regulations I sent, or the arguments I made, the answer was still the same. Well, the answers were sort of the same. I quickly realized that I got different information from different people, which made the process all the more frustrating. It took me multiple calls and messages to ever get to a supervisor, and but when I did, I was basically told that she understood what I was saying but that their legal department had made their decision and they couldn’t do anything about it. All she could recommend was that I send my information and arguments to the appeals department. So I did. And guess what?
Finally, in late February of this year, I WON. Because of my appeal, my insurance company has now changed their policy and is providing double-electric breast pumps at 100% coverage. My pump arrived yesterday, and it’s almost embarrassing how excited I got. I remember back in January when I said to my husband, “I WILL have an electric pump before this is over.” He thought I was being funny. I gave him my best “I’m seriously serious look” and secretly hoped that I was right. There were times that I wanted to give up because the process was a lot of work and my insurance company was more than frustrating. But I stuck with it and am here to tell you that it can be done! I am not by any means an expert, but I can share with you the steps I took in order to get my insurance company to change their policy.
1. Do your research.
Of course, you can skip this step and start with step 2, but approaching your insurance company with some foundational understanding of the ACA and your policy can be helpful in navigating your conversation.
Find out if the ACA applies to you.
The ACA does not apply to all plans. One of the first things you need to determine is whether your plan is considered grandfathered (exempt from ACA) or non-grandfathered (ACA applies). The National Women’s Law Center has some great tips for figuring this out. Also, be aware that certain types of plans such as self-insured plans are exempt from the ACA.
Know what the ACA covers.
The requirement to cover breast pumps is part of the preventive services portion of the ACA. The included services are required to be covered with no cost sharing — meaning, your insurance company is required to pay them in full and you are not responsible for any copay, coinsurance, or deductible. The guidelines state that coverage is required for breastfeeding support, supplies, and counseling, including “[c]omprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” HealthCare.gov is also an excellent source of information about the ACA and explains, “Pregnant and postpartum women have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment. Breastfeeding is one of the most effective preventive measures mothers can take to protect their health and that of their children. One of the barriers for breastfeeding is the cost of purchasing or renting breast pumps and nursing related supplies.”
2. Contact your insurance company.
Communicate with the customer service department of your insurance company to find out if your policy is covered by the ACA (as discussed above), and if so, what type of pump they are covering. Ideally, their answer will be that they are covering electric pumps. If so, this should be a relatively easy process and your pump will hopefully be on your doorstep before you know it. Your only challenge will be to make sure you follow the proper channels in getting the pump, but the representatives will probably be quite familiar with this process since the ACA has been in effect since August 2012. You will most likely be told that you need to order your pump through an in-network durable medical equipment (DME) provider, and you should be able to search for one in the same way you would search for an in-network doctor. To find DME providers who carry Hygeia pumps, check out this helpful post on the Hygeia blog.
However, if you’re like me, you may be told your insurance company is only covering manual pumps. Doesn’t seem fair, does it? The same regulations are being applied to all qualifying plans, so why are some women receiving top-of-the-line double-electric pumps and others only inexpensive manual pumps? The short answer is that the regulations do not make it clear as to what exactly is required. Keep in mind that this is new territory. It is unlikely that insurance companies will be able to continue to go on with differing interpretations of the same regulations for very long. But for now, each insurance company is applying the requirements of the ACA as they see fit. I liken it to how, as a parent, you make a rule that seems pretty clear to you. Let’s say, “No running in the house.” You see your son running and ask him to stop. “But Moooooom, I wasn’t running, I was jogging.” Or “I wasn’t running in the house, I was running in the garage.” Right now, we’re in the stage where the legal departments of insurance companies are making their own arguments about what the law actually requires, and unfortunately, many are trying to read the guidelines as narrowly (read: cheaply) as possible.
As an additional tip, be strategic about whether you communicate with your insurance company by phone or in writing. I tried to use my company’s online message center as much as possible in order to have a written record of our communication. I was very grateful for this later when I started the appeals process as I had written proof of most everything they had said to me. However, there were times that I chose to communicate over the phone, either because I needed an answer quicker than the message center could provide or I needed to reiterate questions that they were either overlooking or ignoring in our online messages. If you choose to communicate over the phone, don’t be afraid to ask to speak to a supervisor and ask for important things in writing. Also, try to keep some sort of record of your telephone communication – the time/date of your call, who you spoke with, what they told you, etc. It helps establish credibility in the future so you don’t find yourself in the position of having to say, “Well, awhile back someone told me _____.”
Also, note that coverage for breast pumps under the ACA is completely separate from whether breast pumps are covered under a DME provision in your policy. Typically, DME will only be covered with proof of medical necessity, and even then, will require cost-sharing between you and your insurance company. You may have to remind the representatives with whom you speak that you are not asking about DME coverage, but for ACA coverage.
3. Formulate your arguments.
At this point, you know what is supposed to be covered, and you also know what your insurer is currently covering. What do you do if those don’t match up? You don’t have to give up! At this point, I was incredibly frustrated (that’s putting it nicely). Not only did I believe that my insurance company was not meeting the requirements of the law, but at this point I had received numerous inconsistent answers and had my questions ignored multiple times. But at the same time, I knew there were countless other women in the same position, so it made me want to get to the bottom of it even more.
First, collect all the information you have from your communication with your insurance company, and see what else you can find that would support your argument that an electric pump should be covered. Through simple Google searches I was able to find other supporting information such as brochures from other insurance companies stating they were covering electric pumps as a result of the ACA.
After reviewing all I had, I decided to take a two-part approach with the arguments I made with my insurance company. One, I argued that the guidelines state that the “costs for renting breastfeeding equipment” are required to be covered. Since manual pumps are not permitted to be rentals due to their inability to be adequately sterilized, it did not follow that providing a manual pump would meet the requirements.
Secondly, I argued that the provision of only a manual pump did not satisfy the intent of the ACA requirements. I reiterated that the intent stated in these provisions is to promote breastfeeding and remove barriers preventing mothers from successful breastfeeding. The guidelines specifically reference the cost of breast pumps being one of these barriers. It did not make sense that an inexpensive manual pump would be what the authors of the ACA or related guidelines had in mind as a solution to this problem. The cost of a manual pump is minimal, and they are intended only for occasional use. For a mother who needs to pump regularly in order to continue breastfeeding her baby, it would not follow that a manual pump would remove any barriers or promote breastfeeding because it would not be sufficient to meet her needs. Most mothers who pump frequently or exclusively are only able to do so with a double-electric pump, and it is the cost of that pump (typically ten times the cost of a manual pump or more) that is a frequent barrier to many mothers.
Of course, these arguments are the ones that I personally felt were most compelling based on my own situation and the information my insurance company had given me, but yours may be different. And unfortunately, I have no way of knowing what exactly my insurance company found to be most persuasive in changing their mind. I simply decided to make as many arguments as I could since I never knew how many chances I would get or when an actual decision-maker might be made aware of my complaints.
4. Make your case.
There are several options for your next step, and you can choose to pursue them one at a time (not necessarily in the order I listed) or pursue several at once.
Appeal through your insurance company. Find out what your insurance company’s appeals process is and start it. It may be a little more challenging because you don’t actually have the denial of a processed claim to appeal. I spent several weeks simply going back and forth between representatives and supervisors in hopes that I would get somewhere before deciding that an appeal was the only way to get my arguments before an actual decision-maker. You will likely have to put together all your information (communication, arguments, questions) and submit it formally for review. I would also recommend trying to briefly address how this affects you personally. You never know when your story may resonate with someone. Ultimately, my appeal ended up at both the appeals review board as well as the legal department because they recognized the magnitude of this decision. Whatever the determination, it would apply across the board to all their members.
File a complaint with your state’s Department of Insurance or similar regulatory agency. Insurance companies/agents/brokers/etc. are regulated by state agencies. I found mine by searching online for “California Department of Insurance” and then navigating through the portion of their website designed for consumers. I was able to quickly and easily file my complaint online. If your insurance company is located in a different state than you, you might also consider filing with that state instead of or in addition to your own. I ended up filing with both.
Talk to your employer’s HR department (or your spouse/partner’s employer if they are the subscriber). My husband’s employer’s head of HR ended up being one of my biggest advocates. She recognized that we were not only being denied benefits to which we may very well be entitled, but we were also being given inconsistent information and many of our questions weren’t being addressed. She was able to help us escalate the issue within the insurance company, and even involve the company’s benefits liaison in pushing the issue.
5. Hurry up and wait (hopefully for good news).
Unfortunately, this can be a lengthy process. Complaints with the state can take several months to process. If you end up filing an appeal, it can also be lengthy. Your insurance company is typically required to make a decision in a certain amount of time. However, it took several weeks of going back and forth before we realized an official appeal was our only option in getting the issue in front of someone who had the authority to change the policy. The appeal then took the full amount of time because it was escalated to such a very high level.
When I received the letter that my insurance company had decided to change their policy to cover electric pumps based on my appeal, it was pretty exciting. Was the process fun? Absolutely not. There were so many times I felt like giving up. It seems cruel that this issue presents itself during some of the most grueling times in a new mom’s life. But I would encourage you to keep at it and remember the widespread effect that a company-wide change in policy can mean. A decision in your favor will likely mean not only an electric pump for you, but also electric pumps for all the mothers with your insurance who are nursing or planning to nurse. I know it sounds cheesy, but it felt good to know that all the hard work paid off and that I had hopefully made a difference in the lives of other moms and babies. It’s also pretty awesome to be able to tell people you went all Erin Brockovich on your insurance company, right?