Insurance Details

We are currently seeing families in our Red Bank and Manasquan locations. We are doing some home visits but they are very limited at this time and we do charge a $50 travel fee for in home convenience that is not covered by insurance (Monmouth and Ocean Counties only).

We are in network with Tricare, Aetna, Amerihealth, United Healthcare, CIGNA, Independence Blue Cross Blue Shield, Anthem Blue Cross Blue Shield, Primera, and most Blue Cross Blue Shield National PPO plans. We are not in network with Blue Cross Blue Shield Federal, Highmark, HMO, or EPO or most Omnia plans. Should you cancel your appointment with less than 24 hours notice you will be charged a $50 cancellation fee that is not covered by insurance

Out of network/Self Pay 

Our out-of-pocket fee for out of network patients is $285 for an initial appointment (this includes initial bottle refusal appointments for non-lactating families). $190 for all follow-ups. Private prenatal appointments are $175, Return to work/pumping/exclusive pumping/starting solids prep consults are $185. In-home starting solids/baby led weaning consults are $275 (+ $50 in home convenience fee). *Michelle is no longer accepting BCBS Omnia out of pocket patients. We can provide you with a superbill to submit to your insurance company for potential reimbursement. If you participate in a health share, we provide a paid invoice and letter of medical necessity for you to submit to your health share.

The Affordable Care Act requires that all new health plans cover lactation support and supplies without cost-sharing “for the duration of breastfeeding,” which means plans may not apply any co-payment, co-insurance, or deductible to these benefits. Insurance companies can impose some limitations such as where to obtain the equipment and requiring the purchase, rather than rental, of a pump.

Private insurance: The relatively few exceptions are “grandfathered” plans that do not have to comply. The most effective way to find out if your plan is grandfathered or not is to call your insurance carrier and to ask. All plans purchased on the Health Insurance Marketplaces must cover lactation support and supplies.

Medicaid: Coverage for lactation support and supplies will vary by state and by type of Medicaid coverage.

Military Benefits: TRICARE is finally covering lactation support and supplies. Be sure to check with your plan for specific details.

If you are having problems obtaining lactation benefits, visit www.nwlc.org (National Womens Law Center) or call them at 1-866-745-5487 

Where to Start?

1. First determine if your plan is grandfathered or not. If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.

2. If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out of network exemption (or gap exemption). Make sure to ask for an exemption for several visits since most cases require 2-4 visits and more complex cases can require more. Here is the information you need from us to get pre-approval:

Provider Name: Michelle Ariante, MA, IBCLC

Individual NPI # 1073986840

Group NPI # 1134985989

EIN # 47-5501197

CAQH # 13649813

IBCLC Licence # L-83369

NJ Address: 208 E Main St.; Manasquan, NJ 08736

Phone: 732-977-6444

Diagnosis Code: Z39.1 

Procedural Codes: OFFICE: 99404 and S9443 

Laura Sarantinoudis Jones, BA, IBCLC 

NPI # 1407206543

EIN # 15-1741532

CAQH # 13847456

NJ Address: 130 Maple Avenue; Red Bank, NJ 07701

Phone: 732-439-7972

Diagnosis Code: z39.1 

Procedural Codes: OFFICE: 99404 and S9443 

1. Write the date, time and NAME of the supervisor or agent who tells you that you are covered. Ask them to note your file and if possible to send you confirmation of the conversation and the information they gave you regarding the coverage under your benefits.

2. If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.

3. It can be useful to get a referral from your pediatrician and or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.

4. POSSIBLE SCRIPT TO USE WHEN CALLING: If your pediatrician conceded to giving you the referral then make sure to start the script with this information.

You: I understand that under the Affordable Care Act all plans are required to cover breastfeeding support and supplies without cost-sharing. Can you confirm that my plan follows this Federal guideline?

Insurance Agent: NO, we don’t cover breast pumps or lactation consultants.

You: Is my plan grandfathered?

Insurance Agent: NO, your plan is not grandfathered, but we don’t provide this benefit.

You: The healthcare law requires that you provide this benefit. Can I speak with a supervisor to make sure this is the correct information about this policy?

Repeat these questions to the supervisor and insist that under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding.”

In Network and Self-Pay Services

If your plan requires you to use in network providers, and your plan is not Aetna, Blue Cross Blue Shield (PPO), CIGNA, Tricare, United Healthcare or Amerihealth and you live in New Jersey, you will not find an in network provider with the exception of 2-3 breastfeeding medicine doctors that are also IBCLCs who treat more advanced clinical lactation issues. Insist that there is no in network provider within 25 miles and because they are required to cover preventive lactation services they must give you an out of network exemption. This last requires the following information from the lactation consultant: NPI number, Federal Tax ID, address and phone number and the diagnostic and procedural codes the lactation consultant will use to bill for your services. These extra steps are a pain but may be worth it if you can get at least partial reimbursement. 

Appealing a Denial for Lactation Equipment (Breast Pump)

SAMPLE LETTER NO COVERAGE POLICY FOR BREAST PUMP 

To Whom It May Concern:

I am enrolled in a [INSURANCE COMPANY NAME] plan, policy number [POLICY NUMBER]. I recently tried to purchase a pump through my health insurance. The Patient Protection and Affordable Care Act requires that my insurance coverage of this preventive service be with no cost-sharing. However, when I contacted [INSURANCE COMPANY NAME] about the coverage, I was told I could not get coverage of [BREAST PUMP REQUESTED]. 

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services which must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment [] for the duration of breastfeeding” (see attachment). 

My health insurance plan is non-grandfathered. Thus, the plan must comply with the women’s preventive services provision.

[INCLUDE THIS PARAGRAPH IF YOUR PLAN DOES NOT HAVE A CLEAR PROCESS TO GET A PUMP] My health care provider has prescribed that I use [BREAST PUMP REQUESTED]. The insurance plan has not established a process for me to obtain a pump, such as through a durable medical equipment supplier, and thus it remains an over-the-counter product for the purposes of my plan. As the FAQs on the preventive services (dated February 20, 2013) state, “OTC recommended items and services must be covered without cost-sharing…when prescribed by a health care provider.”  Accordingly, [INSURANCE COMPANY] must cover [BREAST PUMP REQUESTED] as required under the Affordable Care Act. 

LAST PARAGRAPH OPTIONS: (1) I have spent [TOTAL AMOUNT] out-of-pocket on [NAME OF BREAST PUMP], despite the fact that it should have been covered. I have attached copies of receipts which document these out-of-pocket expenses. [COMPANY NAME] must rectify this situation by reimbursing me for the out-of-pocket costs I have incurred during the period it was not covered without cost-sharing. Furthermore, [COMPANY NAME] must ensure breastfeeding support and supplies, including lactation counseling are covered without cost-sharing in the future by changing any corporate policies that do not comply with the Affordable Care Act. 

Or  (2) I am prepared to order [BREAST PUMP REQUESTED] when [COMPANY NAME] assures that I have coverage without cost-sharing. I expect that [COMPANY NAME] will rectify this situation and notify me within 30 days of receipt of this letter that [BREAST PUMP REQUESTED] will be covered without cost-sharing.

Sincerely,

[YOUR SIGNATURE]

Encl:

Frequently Asked Questions about the Affordable Care Act (Part XII) (available at http://www.dol.gov/ebsa/faqs/faq-aca12.html) Copies of Receipts Documenting Out-of-Pocket Costs

Appealing a Denial for Lactation Support

SAMPLE LETTER COVERAGE FOR LACTATION CONSULTANT 

To Whom It May Concern:  

I am enrolled in a [INSURANCE COMPANY NAME] plan, policy number [POLICY NUMBER]. I recently tried to access lactation counseling that should be covered by my health insurance. The Patient Protection and Affordable Care Act requires insurance coverage of breastfeeding support and supplies with no cost-sharing. However, when I contacted [INSURANCE COMPANY NAME] about the coverage by [SPECIFY METHOD, PHONE] on [DATE], I was told I could not get coverage of [LACTATION COUNSELING] because [SPECIFY REASON, SUCH AS NO IN-NETWORK PROVIDERS]. 

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding” (see attachment). 

My health insurance plan is non-grandfathered and the plan year started on [PLAN YEAR DATE]. Thus, the plan must comply with the women’s preventive services provision. 

The insurance plan has not established a process for me to obtain in-network lactation counseling, as required by federal law. Federal guidance on the preventive services clarify that, “… if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.”

Since [PLAN YEAR DATE], I have spent [TOTAL AMOUNT] out-of-pocket on 

[LACTATION COUNSELING], despite the fact that it should have been covered during that time. I have attached copies of receipts which document these out-of-pocket expenses. [COMPANY NAME] must rectify this situation by reimbursing me for the out-of-pocket costs I have incurred during the period it was not covered without cost-sharing. Furthermore, [COMPANY NAME] must ensure breastfeeding support and supplies, including lactation counseling are covered without cost-sharing in the future by changing any corporate policies that do not comply with the Affordable Care Act. 

Sincerely, 

[YOUR SIGNATURE] 

Encl: Frequently Asked Questions about the Affordable Care Act (Part XII) (available at http://www.dol.gov/ebsa/faqs/faq-aca12.html)
Copies of Receipts Documenting Out-of-Pocket Costs