Lactation coverage & Book appointment
* PLEASE READ IMPORTANT INFORMATION ABOUT COVERAGE BEFORE BOOKING BELOW*
Lactation Consultations for the lactating parent are covered under "Preventative Care" as part of the Affordable Care Act of 2012 (ACA). This law extends to ALL insurance companies regardless of In-Network status (however may not apply to some "grandfathered-in" plans).
Please see NWLC BREASTFEEDING TOOLKIT for more information on this law and your rights to lactation care. It is recommended that you contact your insurance carrier for more specific details regarding your coverage. Please document the name of the representative you speak to and a reference number for your own records in case of any discrepancies with how a claim is processed.
*A "home visit" fee is applied to ALL consultations. Coverage by insurance varies.
*IF APPLICABLE: Long Distance Fees will apply for travel more than 20 miles and will be due at time of visit. (you will be made aware if this fee applies after booking).
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I have an existing contract with Aetna, Cigna, and United Healthcare (and SOME of their subsidiary companies) and will submit claims directly to them after each visit. Please note that claims are submitted for EACH member (lactating parent and/or each child) and are based on time and services rendered. Out-of-pocket dues/additional fees may be assigned depending on your plan. If there are any out-of-pocket costs determined by insurance after claims are processed, my contract obligates that the balance be invoiced to you.
Most plans cover 100% for the lactating parent (the ACA only covers preventative lactation care for the lactating parent). However, there may be a limit to the number of codes that your insurance allows and that can impact your coverage. If your child is part of the consultation, there may be out-of-pocket costs dependent on your plan (cost-share) when they process the claim.
PLEASE NOTE :
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If you have multiple insurance carriers and Aetna/Cigna/UHC is NOT set as your "primary" insurance - you will need to book a SELF-PAY appointment and pay the fees at the time of the visit. We can submit it to Aetna/Cigna/UHC after your primary insurance has processed the claims.
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If the child(ren) is on a different insurance plan from the IN-NETWORK providers, the Self-Pay fee will apply for baby and be due at the time of the visit (please note this when booking and I will respond with fee information). *DO NOT* book a separate appointment for your child(ren). I will provide you with a Superbill after our visit that you will be able to submit to the insurance company to seek reimbursement.
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Some plans will not cover for in-home services. Coverage for "home visit" fee varies by insurance and any balances will be billed/invoiced to the client.
AETNA will typically cover 100% for certain codes that are used for both the lactating parent and child(ren). Lactation consultations are billed according to time spent on the particular services rendered for each patient being examined at the visit. The ACA only requires that preventative lactation care is covered for the lactating parent (please visit NWLC BREASTFEEDING TOOLKIT for more information regarding this coverage). Aetna will provide some coverage for the child(ren), but fees may apply due to your plan benefits. Insurance representatives may not disclose that your child is considered a separate patient. Any out-of-pocket costs are assigned by the insurance companies (cost-share) when they process the claim and any balances will be invoiced to you.
As a courtesy, I like to provide my clients with details of their specific plan (may not be available for certain subsidiaries) in order to estimate what may be due out-of-pocket for our visits. This will be emailed to you before our scheduled appointment for your financial consideration.
Please see AETNA FAQs for more information regarding how Aetna covers lactation consultations.
CIGNA will typically cover 100% for lactation consultations. Consultations are billed according to time spent on the particular services rendered for each patient being examined at the visit. The ACA only covers preventative lactation care for the lactating parent. Please visit NWLC BREASTFEEDING TOOLKIT for more information regarding this coverage. Your baby will likely receive some coverage for these consultations, but CIGNA may designate out-of-pocket costs depending on your plan (cost-share). After claims are processed, any balances deemed "patient responsibility" will be invoiced to you.
PLEASE NOTE :
CIGNA does not cover the "home visit" fee. A $50.00 fee applies at each appointment (separate from the the "Long Distance Fee" when applicable). Payment is due at the end of our visit.
United Healthcare will typically cover 100% for lactation consultations. Consultations are billed according to time spent on the particular services rendered for each patient being examined at the visit. The ACA only covers preventative lactation care for the lactating parent. Please visit NWLC BREASTFEEDING TOOLKIT for more information regarding this coverage. Your baby will likely receive some coverage for these consultations, but UHC may designate out-of-pocket costs depending on your plan (cost-share). After claims are processed, any balances deemed "patient responsibility" will be invoiced to you.
PLEASE NOTE :
UHC does not cover the "home visit" fee. A $50.00 fee applies at each appointment (separate from the the "Long Distance Fee" when applicable). Payment is due at the end of our visit.
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(i.e., BCBS, Amerihealth, etc.)
self-pay
Unfortunately, I am not In-Network with some insurance carriers. Payment for our consultation will be due out-of-pocket at the time of our visit (fees are listed when you book your appointment). You will be provided with a Superbill after our visit that can be submitted by you to your insurance carrier in order to seek reimbursement for the fees you paid. I am unable to view how your insurance will cover and reimburse you. Please call them for additional information.
If you are uninsured or do not plan to submit a claim for reimbursement, I will provide you with a Good Faith Estimate for expected out-of-pocket costs in accordance with the "No Surprises Act"(see CMS.gov for information regarding this).
GAP EXCEPTION
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You can request a "gap exception" from your insurance provider when there are no IBCLC providers "In-Network" or none that are local to you.
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If approved, they should process the claim according to your "In-Network" benefits (with the Superbill I provide you after our visit).
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They may need the following information:
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Nancy Tsen, IBCLC
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Hackettstown, NJ 07840
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Phone: (973)349-5016
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Fax: (908)441-8775
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NPI#: 1992219869
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EIN#: 82-3520109
Codes likely used:
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Diagnosis code: Z39.1
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Procedure codes: S9443, 99404, and 99344
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