Last November, Mary Boyle welcomed a baby girl named Maisie to their family. Boyle said she was determined to breastfeed.
“Those first few weeks are really, really hard as your baby is learning how to breastfeed, as you’re trying to re-teach yourself,” said Boyle.
Like many moms, Boyle struggled.
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“I was bleeding. It was really, really challenging and I was ready to give up. I was ready to stop breastfeeding,” said Boyle. “I knew I had to engage an expert, a specialist to help understand what my baby’s specific needs are. I don’t need blanket advice.”
Boyle’s OBGYN wrote a prescription, recommending a visit with a lactation consultant.
After one session, Boyle noticed a major improvement.
“Within a week or two, those issues had cleared up based on the advice she gave me. I am thrilled to report I am still breastfeeding my baby today,” said Boyle.
Boyle paid $195 for the in-home consultation then submitted the bill to her insurance company at the time, Cigna, for reimbursement.
Cigna denied the claim, saying Boyle’s provider was out-of-network.
Boyle tells NBC 5 Responds, she couldn’t find a lactation consultant in-network.
“When I actually searched for a specialist for lactation provider, lactation consultant, I searched every possible term, nothing came up. Not within 10 miles, not within a 100-mile radius,” Boyle explained.
The Affordable Care Act says health insurance plans must cover breastfeeding support and supplies at no cost to patients.
So, Boyle appealed Cigna’s decision, twice. Cigna sent back two more denial letters.
“They kept saying you’re not using a provider that is in-network, but the problem is they don’t offer any in-network providers,” said Boyle.
NBC 5 Responds wrote to Cigna about Boyle’s claim.
Cigna wrote back and said Boyle should not have been denied reimbursement.
“Thank you for bringing this to our attention. We’ve reviewed the claim, determined it should be paid in full and apologize for the hardship this has caused our customer. At Cigna, we strive to do all we can to support a mother’s choice to breastfeed by providing access to lactation consultants regardless of network status and will make sure this customer and her child get the support they need.”
Breastfeeding advocates said Boyle’s ordeal is not unusual and not limited to one healthcare company.
Susanne Madden, Chief Operating Officer of the National Breastfeeding Center, an advocacy and consulting group, said federal law isn’t specific enough about how breastfeeding support services should be covered.
“Unfortunately, if you read the actual language of the law, you will discover that it is very vague. It just says the insurance companies must pay for trained providers, not trained in lactation, just trained providers and that they will cover these services,” explained Madden.
“Therein lies the problem,” Madden added.
Madden said insurance companies may define a provider as a pediatrician or OBGYN and many don’t have the training or time to help mothers through breastfeeding challenges.
Though some pediatric practices offer in-house lactation consulting, Madden said it’s not common.
NBC 5 Responds spoke to lactation consultants who describe a system that makes it difficult to become an in-network provider places barriers for families looking for reimbursement.
Kara Rosales, IBCLC, of For Babies’ Sake worked with Boyle. She said most clients are never reimbursed for the service.
“I get letters from the insurance companies that tell me whether they paid a claim, how much they paid for it,” said Rosales.
“No matter how many times we submit the claims, no matter how many different claim numbers we give them or CPT codes, they're just going to find a way to not cover. That's really frustrating,” Rosales added.
Another lactation consultant, not involved in Boyle’s case, describes inconsistencies in reimbursement.
“Sometimes the plans will allow you to go out-of-network and then you can turn in a receipt with some codes and they will reimburse fairly easily,” said Stephanie Brown, RN, IBCLC with Nourish and Nurture Lactation Consulting.
“Then other plans just are very difficult to get reimbursement. You could use some coding with one family and they get reimbursed. And the exact same company, you don't get reimbursed with the same coding,” explained Brown.
So, what should a parent do?
Boyle wrote to the Texas Insurance Commissioner. While the Texas Department of Insurance does not regulate employer self-funded plans that most people get through work, the agency can help escalate a complaint.
“It should be covered by most comprehensive plans. If it's not, that's when you have to appeal to the insurance company,” said Ben Gonzalez with the Texas Department of Insurance. “You want to talk to the plan and ask them, hey, I thought this was supposed to be covered or why was it denied?”
A few plans may be grandfathered in and not subject to ACA preventative care requirements.
If you’re not sure about the type of plan you have, you can start by calling the Texas Department of Insurance Help Line at 1-800-252-3439.
You can also call the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 to discuss specifics about your plan and benefits.
The Texas Breastfeeding Coalition complied sample letters customers can send to insurance companies to appeal the denial of benefits.
The National Women’s Law Center offers this fact sheet to help families understand their rights.
The National Women’s Law Center explains coverage problems that prevent women from accessing breastfeeding support.
Madden said if you have insurance coverage through your employer and your insurance company isn’t working with you, ask your Human Resources department, your boss or company owner to advocate for you.
Madden believes problems persist because families with newborns often don’t have the time to haggle.
“The reality is moms with newborn babies are busy trying to feed their babies. They don't have time to fight this out with their employers and the insurers and everybody else,” said Madden.
She said that won’t change unless lawmakers step in.
“It was a very frustrating process and I’ve put hours and hours and hours of my time into this,” said Boyle. “I can only imagine other mothers who have stopped earlier than I did because it takes up too much time and it’s exhausting when you’re a new mom to have to go through this process.”
Boyle eventually did get a check from Cigna. It took seven months of persistence.
“It more became about the principal of the matter and I felt like my rights were not being upheld,” said Boyle.
She hopes to shed light on the issue – pointing to the cost-saving and health benefits of breastfeeding.
“We are talking about babies, we are talking about life we are trying to nurture. This area is so important and we need support at the federal and state level to make sure mothers get the support they need.”
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