Vague ACA Guidelines Create Obstacles for New Moms Needing Breast Pumps

A few months ago, Angela Bass experienced a fairly common problem for mothers who have recently started breastfeeding. Her two-month-old daughter was having trouble nursing, and as a result, Bass was suffering from painful engorgement, a condition that can lead to an infection called mastitis. Her doctor prescribed an electric breast pump to help Bass manage her milk supply while working with a lactation consultant to figure out why her daughter wasn’t able to nurse.

Initially, filling the prescription seemed easy, but Bass soon found herself spending hours navigating a complicated and obscure process through her private insurance provider to obtain the pump. It ultimately took a week to find a medical device supplier who would accept the prescription, and in the end, she was still mistakenly billed for it.

“You have a new baby. You’re fatigued. You’re overwhelmed,” said Bass, 27, of Victorville. “I had to jump through hoop after hoop.”

Under the Affordable Care Act, health plans are required to cover the cost of breast pumps for women who need them for medical reasons or because they work or are students. When the provision went into effect in 2012, it was largely heralded as a major victory for mothers and infants.

Two years later, though, advocacy groups say a lack of guidelines has led to inconsistent coverage in California and across the nation. They say that convoluted processes make it impossible, or nearly impossible, for some women to obtain breast pumps when they are needed and that there are discrepancies in the type of breast pump women are able to obtain and the circumstances under which a pump is covered.

“We’re finding it’s a big problem,” said Robbie Gonzalez-Dow, executive director of the California Breastfeeding Coalition. “Because there really aren’t guidelines, insurance plans interpret it how they want. Women are at the whim of those companies.”

Breastfeeding Widely Promoted

Breastfeeding is widely promoted by medical providers because of a wide body of research showing its optimal nutritional value and positive health outcomes, such as reducing rates of acute and chronic conditions, including gastrointestinal infections, ear infections, asthma, diabetes and obesity.

According to HealthCare.gov, it’s up to the doctor and patient to determine what is needed, although health plans “may provide guidance on whether the covered pump is manual or electric, how long the coverage of a rented pump lasts, and when they’ll provide the pump.”

“Coverage must extend for the duration of breastfeeding, and we certainly see policies that are contradictory to that guidance,” said Karen Davenport, director of health policy at the National Women’s Law Center.

Different types of breast pumps are made for a variety of situations, and those manufactured for frequent use can be expensive. Breast pumps are particularly important for women who cannot directly nurse their babies, such as when infants must be placed in Neonatal Intensive Care Units. Under those circumstances, a hospital-grade electric pump is usually required, which costs $1,000 to $2,000 or $80 per month to rent. “Personal” breast pumps, used most often by working mothers, typically retail for $100 to $300 in California. Nationally, nearly 60% of women with infants are working mothers, according to the Bureau of Labor Statistics.

“We see plans that say they will only cover a manual pump. The (ACA) doesn’t speak to what kind of pump it has to be,” Davenport said.

“Sometimes the wrong pump is being given, but sometimes nothing is being given to mothers until it’s too late,” said Marsha Walker, director of public policy for the United States Lactation Consultant Association. “There is nothing the insurers must adhere to in terms of protocols. They’ve made it up themselves.”

Lactation consultants said they have witnessed situations where mothers with babies in NICU have been given manual pumps, which typically cost $40 and are inadequate for a new mother to establish her milk supply. In other cases, complicated approval processes have led to weeks-long delays in women receiving breast pumps.

A Local Issue

Because the ACA left it up to health plans to implement the requirement, mothers themselves must figure out how to obtain a breast pump, and their medical providers may not be able to help.

“If a provider sees 20 women a day and they all have different insurance plans, it’s hard to know what their benefits are for each plan,” Gonzalez-Dow said.

In some cases, health plans will provide a pump before a mother has given birth, and the pump provided might not suit the woman’s needs after giving birth. In other cases, the mother must have given birth to be eligible. Some women are only eligible for manual pumps, while under the same circumstances, other plans cover electric pumps. Advocates and lactation consultants said the inconsistencies cut across public and private plans and vary from county to county in California.

“It’s a real local problem because health plans can operate differently in each county,” Gonzalez-Dow said. This particularly applies to Medi-Cal managed care plans, which differ by county, she said.Medi-Cal is California’s Medicaid program.

Rose Mary Garrone, director of nursing for Fresno County Department of Public Health, said the issue has been largely avoided for local low-income mothers because the county has worked closely with its public managed care plans.

“When it was first a benefit, we made sure they were aware of it,” she said.

In Sacramento County, however, some health plans were sending mothers to the local WIC program for pumps, when the health plans should have provided the pumps, said Samantha Slaughter, regional breastfeeding liaison with the Community Resource Project’s Special Supplemental Nutrition Program for Women, Infants, and Children.

“We’ve had a number of mothers who have spent weeks or a month or two trying to get a breast pump, and some of them gave up,” she said.

Conflicting Oversight

There are differing opinions on how the process for obtaining a breast pump should be regulated, and who is responsible for simplifying or streamlining the process. Should state insurance commissioners take up the issue? Should the federal government issue a directive? Should it fall to individual counties to police their Medi-Cal managed care plans? If a plan is through a health insurance exchange, should the exchange fix the problem?

The United States Breastfeeding Committee has issued recommendations on how insurance companies should implement the provision. The California Breastfeeding Coalition also has released a policy brief for health plans on providing breastfeeding support.

But most of the onus appears to fall on breastfeeding mothers to institute change, Davenport said.

There is some recourse for women who have encountered difficulties. If they have a private health plan, they can appeal their health insurer’s decision, or file a complaint with the state insurance commissioner’s office, Walker said. They can also notify advocacy groups, and if a plan is through the exchange, they can notify Covered California officials.

Nancy Kincaid, a spokesperson for the California Department of Insurance, said complaints have been received here and there over the last year. But she stressed that it’s up to the insurer as to what is provided, and under some plans, only a manual pump is covered.

Karen Farley, program manager for the California WIC Association, said the reason there are few complaints is because mothers who have recently given birth and are trying to nurse their infants aren’t in a position to file complaints.

“It isn’t going to solve their problem when they are trying to feed their baby,” she said. “Regardless, they shouldn’t have to be complaining.”

Advocacy groups and California DOI offer online and telephone help to providers and new mothers:

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