Dr. Holly S. Puritz, an ob.gyn. in Norfolk, Va., wasn’t surprised by the findings of a recent report that claims insurers are failing to cover breastfeeding services as required by the Affordable Care Act.
“If I’m being charitable, I would say lots of the new rules are confusing and difficult for anyone to sort out,” said Dr. Puritz, who is in private practice and is also medical director for labor and delivery at Sentara Leigh Hospital. “However, my gut tells me that anything a company can put off paying for any amount of time equals profit, and most insurance companies have shareholders they answer to.”
The National Women’s Law Center (NWLC) found that at least 20 insurance companies are disregarding some ACA requirements by limiting coverage of breast pump purchases or failing to provide in-network lactation counselors.
For its report, published on May 21, NWLC analyzed coverage of breastfeeding support and supplies offered in the health insurance marketplaces of 15 states during 2014 and 2015. Researchers also reviewed personal accounts from patients collected from emails and calls to the center’s hotline.
The NWLC found that some health plans are placing improper coverage limits on breastfeeding benefits, including only allowing women to receive lactation services within 2 months of delivery; failing to cover breast pumps until after a baby is born; and denying claims for out-of-network lactation consultants even when in-network services are not available.
The ACA requires that insurers cover breastfeeding supplies and counseling without copays, deductibles, or coinsurance.
“The Affordable Care Act has made dramatic improvements in women’s health coverage,” Gretchen Borchelt, vice president for health and reproductive rights at NWLC, said in a statement. “If insurance companies fail to comply, they are illegally blocking further progress toward helping women breastfeed successfully. Everyone involved, from insurance companies to federal regulators, must work together to ensure that breastfeeding coverage fulfills the promise of the ACA.”
But America’s Health Insurance Plans (AHIP), a trade group representing the insurance industry, criticized the report, calling the study unscientific and lacking hard data.
“This report presents a distorted picture of reality,” AHIP President and CEO Karen Ignagni said in an interview. “Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys. To use highly selective anecdotes to draw sweeping conclusions about consumers’ coverage does nothing to improve the quality, accessibility, or affordability of health care for individuals and families.”
During its study, NWLC researchers found that physicians were generally very supportive in getting their patients’ help from trained lactation providers when possible, said Anna C. Benyo, NWLC senior health policy analyst. In some cases, pediatricians’ offices had a registered nurse who was also a trained lactation consultant and who could provide some education and support during well-child visits, Ms. Benyo said in an interview.
“But, for the most part, the pediatrician wants women to get help, and then [patients] try to find a provider who takes their insurance, and that’s where things start to fall apart,” Ms. Benyo said. “Their insurance company hasn’t set up a network and when they try to go out-of-network as allowed by federal rules, the plans deny coverage.”
In cases where the type of pump is an issue, Ms. Benyo said physicians sometimes write prescriptions for hospital-grade pumps to help patients get the needed equipment. Under the ACA, insurance plans are not required to cover a certain type of pump, leading some plans to cover only manual pumps and exclude electronic or hospital-grade pumps.
Dr. Puritz said she and her colleagues have written prescriptions for hospital-grade pumps.
“The hospital-grade breast pumps that are now covered [by prescription] are a huge improvement for women who want to breastfeed [versus] the less expensive ones that many women would try as that was what they could afford,” she said in an interview. “They didn’t work well and discouraged many of my patients from continuing to nurse.”
For physicians, seeing patients struggle to obtain insurance coverage for needed medical supplies is frustrating, Dr. Puritz added. She said she has not seen any specific cases involving coverage denials for breastfeeding services, but in general, the problem is troublesome.
“Coverage improves access plain and simple,” Dr. Purtiz said. “The problem is when physicians get denials, it’s lots of extra work for them and their staff. They have to be really committed to make it work.”
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