FAQs
Breastfeeding
Understanding Insurance
Can I use my insurance to cover any of WellNested's services?
- Breastfeeding Support: Depending on your plan, insurance reimbursement is available for lactation consultant (IBCLC) visits. For more detail please read below
- Mother/Baby Nurse: Currently, insurance reimbursement is not available for nursing care. However, we do accept FSA/HSA funds for payment.
What do I need to know about using insurance to cover a visit with a lactation consultant (IBCLC) booked through WellNested?
Since the Affordable Care Act became law in 2010, all new health plans are required to provide coverage for breastfeeding support and supplies. As expected, every health plan interprets that differently! We’re here to help you figure out how to use your coverage.
- Only consultations from International Board Certified Lactation Consultants (IBCLCs) are covered by insurance. Certified Lactation Consultants can be booked at less-expensive rates, but are not covered. This is representative of the difference in their education and training.
- Coverage type: Each plan offers different types of coverage, if at all
- In-network: Lactation consultants exist that are “in-network” for your insurance, meaning they bill your insurance directly and you don’t pay anything out of pocket
- Out-of-network: You have to pay out of pocket for the visit, and your insurance will pay all, some or none of the cost. Claims paperwork is required where reimbursement is possible. No worries - we can help you with that!
- Any IBCLC can care for you if you have an out-of-network plan. No matter what, you need to submit a claim if you want reimbursement
- No coverage: Your plan doesn’t provide offer lactation consultant coverage.Coverage type: Each plan offers different types of coverage, if at all
- Visit type covered: To our knowledge, if your insurance plan pays for lactation consultants at all, they will also be paying for virtual and virtual plus visits.
- Likelihood of reimbursement
- Unfortunately, all insurance companies don’t play fair; some make it easy to get reimbursement and some fight it. We’ll let you know how likely it is to receive reimbursement because, we know, expenses with a baby absolutely add up
- High likelihood: It is guaranteed that you will receive reimbursement
- Moderate likelihood: Company might push back on the claim, but it’s likely you will see a payout if there is a coding error, or if you call
- Low likelihood: Company historically fights claims, calling into question your true ability to receive reimbursement. It’s not impossible, just not guaranteed
- Unfortunately, all insurance companies don’t play fair; some make it easy to get reimbursement and some fight it. We’ll let you know how likely it is to receive reimbursement because, we know, expenses with a baby absolutely add up
- How do we know this?
- Lactation consultants have been pursuing reimbursement for years and dealing with the paperwork. Their historical knowledge across many providers and billers informs our assessment.
- If it’s not covered by my insurance plan, what do I do?
- Use HSA/FSA funding (if available)
- Call us! We can talk through local, group-based options that you might want to consider first
Insurance Coverage for Lactation Consultations
Massachusetts Based Plans Only
| Insurer | Coverage Availability | Out of pocket expense | Likelihood of reimbursement? | # Visits Covered | Are there IBCLCs locally that accept your plan? |
|---|---|---|---|---|---|
| Aetna | In-network | No | Not applicable | Up to 6 per calendar year | Yes! |
| Allways | Out-of-network | Yes, but fully reimbursed | High | Unlimited (but may vary by plan) | No; you can find any IBCLC you like and submit for reimbursement |
| Blue Cross Blue Shield - MA | Out-of-network | Yes, but fully reimbursed | High | Up to 6 per calendar year | No; you can find any IBCLC you like and submit for reimbursement |
| Blue Cross Blue Shield - Federal | Out-of-network | Yes, 100% of the cost | No reimbursement | - | No |
| Cigna | Out-of-network | Yes, but potentially reimbursed up to 60% | Low Frequently denied the initial claim; requires multiple submissions | Unknown/undefined** | No; you can find any IBCLC you like and submit for reimbursement |
| Fallon | Out-of-network | Yes, but fully reimbursed (Excludes MassHealth members) | High | Up to 6 visits | No; you can find any IBCLC you like and submit for reimbursement |
| MassHealth | Out-of-network | Yes, 100% of the cost | No reimbursement Select MassHealth plans cover in-hospital or in-OB/GYN office lactation support only | 0 | No; you will need to find support via hospital or OB/GYN office |
| Harvard Pilgrim | Out-of-network | Yes, but fully reimbursed | High | Unknown/undefined** | No; you can find any IBCLC you like and submit for reimbursement |
| TRICARE | In-network (strict) | No | None Cannot pursue out of network providers Only IBCLCs/CLC visits covered if administered by a professional who is also a TRICARE-authorized doctor, physician assistant, nurse practitioner, nurse-midwife, or registered nurse. | Up to 6 outpatient sessions | Highly unlikely Please work through your TRICARE providers to connect with covered professionals |
| Tufts | Out-of-network | Yes, but fully reimbursed | Medium May ask for a letter of medical necessity from a physician | Unknown/undefined** | No; you can find any IBCLC you like and submit for reimbursement |
| Unicare | In-network | No | Not applicable | Unlimited | Yes! |
| United Healthcare | In-network | Depends Only in-network providers work in CT There are no in-network providers in MA | Low Requires gap exemption for MA residents to be obtained prior to visit* | Unknown | Yes! |
| Tufts Health Together | Out-of-network | Yes, 100% of the cost | No reimbursement | - | Yes, see our resources page here for more info www.bewellnested.com/resources |
| Tufts Mass Health | Out-of-network | Yes, 100% of the cost | No reimbursement | - | Yes, see our resources page here for more info www.bewellnested.com/resources |
| Anthem Blue Cross Blue Shield | Out-of-Network | Yes 100% of the cost | Low Frequently denied the claim unless you are with a employer plan (Google) | - | No |
*Identify a lactation consultant you’d like to work with ahead of time and file a gap exemption with your plan to access reimbursement.
**Information is either unknown or undefined internally; no answer is available from the insurance company
