Although breast pumps are covered under the Affordable Care Act, getting the one you want and finding out what your individual policy covers can be complicated (and frustrating) to deal with. Each plan may have different guidelines on the kind of breast pump that is covered in the policy, or if they reimburse after you buy it. In 2018, insurance provider Anthem cut its breast pump reimbursement in half, making it a lot harder for parents relying on insurance to get a quality breast pump.
Mom-to-be Gretchen Evans experienced this frustration—she'd placed a call to her insurance company, only to find out they didn't cover pump purchases, only breast pump rentals, which left her feeling "icky."
"The woman I was speaking with agreed with everything I was saying, but it was the policy of the company and out of her hands," Evans tells Parents. "She even stated she wouldn't be comfortable with the insurance option."
With all the things you need to prepare ahead of your baby's arrival, going back and forth with your insurance company can be less than appealing. Here's how the experts told us to make sure you get the most out of your insurance benefits.
The current healthcare law does cover breast pumps, explains Tina Sherman, campaign director for the Breastfeeding and Paid Leave Campaign at the women's advocacy organization MomsRising.
"Under the Affordable Care Act [ACA] breastfeeding moms are eligible to receive lactation support and breastfeeding equipment and supplies," she tells Parents.com. "Breastfeeding equipment is based on the recommendation of the woman's healthcare provider and may include but is not limited to: double electric breast pumps, including pump parts and maintenance, and breast milk storage supplies."
The problem is that insurance companies interpret this all different ways—some only cover certain brands or models, some require you to get them from an in-network "durable medical equipment supplier" (in other words, not at Target or BuyBuy Baby), some may allow you to submit for reimbursement after you buy it, and some require a prescription from your doctor.
In addition, when you can buy your pump varies, too—some make you wait until after your baby is born, even though that's a major hassle. Older plans written before the law, or "grandfathered," don't have to adhere to the ACA, although they still may offer some benefits.
The bottom line? You have to call to find out. "It's important to contact the individual plan in advance to verify any unique processes and requirements," Abbie Leibowitz, MD, chief medical officer, founder and president emeritus of West's Health Advocate Solutions, tells Parents. "Do not purchase a pump on your own without first confirming the preferred process with the plan, as this may disqualify you from being reimbursed." He advises calling rather than just reading what's online, as individual plans can vary.
Getty Images.If you're getting the runaround or are still confused, see if you have access to a health advocacy service through your insurer or your employer, Dr. Leibowitz suggests. They can help you sort it out. "Similarly, if you have health insurance through your employer, your human resources or benefits representative is a great resource," he says.
Also, talk to your doctor about your individual pumping needs, as this might help push through your pump coverage, especially if your insurance requires a prescription. "If you will be pumping often and require an electric pump, be sure the prescription indicates this to ensure you are covered with the most appropriate pump," Dr. Leibowitz says.
Picking a pump can be confusing—you want to make sure you have the right one, not just the one insurance says it will pay for.
"The type of pump you get depends not only on your needs, but on your body—breasts and nipples come in all shapes and sizes, and different pumps can be better with different supply levels," Sam Rudolph, mom and creator of the unique smart pump Babyation, tells Parents. "The pump that's best for you also depends on your lifestyle. I know some moms that are very happy with their manual pump because pumping isn't part of their daily or weekly routine. On the flip side, moms that hook themselves up to pumps multiple times each day have a different set of needs." Y
our doctor or a lactation consultant—whose services might also be covered by insurance—can help you decide.
OK, so what if you want a pump your plan doesn't cover? Check if you can be reimbursed up to the amount your plan will cover. If not, you might have other options.
"Beyond insurance, few moms know that they may be able to use pre-tax dollars," Melissa Gonzales, president of women's health at Myriad Genetics tells Parents. "Moms may be able to use their flexible spending account (FSA), health savings account (HSA) or health reimbursement account (HRA) to help cover the cost."
It's a lot of legwork to manage when you're trying to get ready for a new baby, but doing your research now may save you money on your pump later. Gonzales has a handy list of questions to ask your insurance company:
* What type of pump can I get (hospital-grade rental pump, double or single electric personal use, manual pump)? Do I have brand options?
* Do I have to get the "recommended" pump or can I choose to purchase one out-of-network and submit the receipt for reimbursement? If yes, what amount will I be reimbursed? Is there a dollar limit on coverage for breast pumps?
* If I have already obtained a breast pump, can I submit a claim for reimbursement?
* When can I get my breast pump—before or after giving birth?
* Where can I get my breast pump? Does it have to be from a designated place (an "in-network" provider) or can I choose where to get it?
* Will I need a prescription from my healthcare provider?
No matter which path you take, know that there are options available to you to get the breast pump that matches your needs. Do your research and plan ahead, so you know what your insurance covers (and doesn't cover) so that you have it figured out by the time your baby arrives.
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After a pretty smooth experience breastfeeding my first four children, my last baby threw me for a loop (as they tend to do) when it came to nursing. Born five weeks early, she refused to nurse. Providing her with breast milk was important to me personally, so I committed myself to joining the world of exclusive pumping (EP).
After a few weeks of round-the-clock pumping with my traditional double electrical wall unit pump — one of the many types of breast pumps available — while I cared for my newborn, four other children who required rides back and forth to school every day and my husband worked outside of the home, I knew I needed help. I decided to look into purchasing the Elvie, a wireless, hands-free pump that would let me pump milk while taking care of the rest of my duties as a mom. The one problem? The Elvie was hella expensive. So I turned to my health insurance plan to see if I could get a breast pump through insurance — those who are experiencing the brunt of the formula shortage might be interested in the same — and here’s what I found out along the way.
Can you get breast pumps through insurance?
Not only can you get a breast pump through your insurance, but legally, your health insurance plan has to cover it for free, without co-pays. All health insurance plans — including Medicaid — must cover breast pumps by law. The only exceptions are a few grandfathered plans, which do not have to offer the coverage, although many still do.
“Thanks to the Affordable Care Act (ACA), health insurance companies now provide coverage for a broad range of women’s health care services, including breast pumps and supplies, typically at no cost to you,” explains Natasha Cantrell, director of individual and family sales for eHealth.
Are breast pumps free with insurance?
Some breast pumps will be 100% free through your health insurance plan. However, there could be rules on what type of breast pump your insurance lets you get, such as manual vs. electric, or only certain brands. Additionally, some plans may only allow you to rent a pump, not keep it.
Other types of health insurance plans may allow you to purchase your own breast pump, then reimburse you up to an allotted amount. For instance, my insurance plan would have covered a traditional pump in full, but because I wanted the Elvie, I purchased the pump on my own, submitted the receipt to my insurance plan and they sent me a check for their allotted amount — which ended up being half of the cost I paid for the pump.
How to Get a Breast Pump Through Insurance
While that all probably sounds great, you’re probably wondering: How do you actually get a breast pump through insurance? There are a few steps you can take:
Step 1: Find out what your insurance covers.
Every insurance plan will be different for what exactly it will cover, so you’ll want to check the specifics for your plan. If you have an online account or app, check the benefits guide under “pregnancy” or “breastfeeding.” I was able to find my information very easily in the online benefits guide. If you can’t find it online, you can also just call your insurance’s benefits number.
Some insurance plans may also reach out to you if you inform them of your pregnancy. For instance, after enrolling in her health insurance plan’s “pregnancy wellness” program, mother of five Gretchen Bossio, received a phone call from a benefits coordinator when she was 32 weeks pregnant to arrange for her breast pump. After confirming the pump she wanted was on the approved list, she was all set. “The pump arrived in the mail a week later,” says Bossio. “Super easy! I was so grateful!”
If you have commercial insurance, you may also be able to get a more expensive pump at a lower cost explains Jason Canzano, managing director of Acelleron. “In these instances, you can ‘upgrade’ by using your insurance to help subsidize the cost of a more expensive pump such a wearable breast pump or a pump that comes with bag and other extras,” he says. Essentially, the price of the pump drops by the amount the insurance company pays the breast pump provider and you would be responsible for the difference.
Step 2: Follow your plan’s steps to apply for the pump.
Again, every plan will be different, which is why it’s important to check with your specific plan about coverage rules. For instance, some plans may require a doctor’s order or preauthorization, some may cover only certain brands or types of pumps, and others will have you apply for a pump through a third-party site.
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For instance, Erin Heger, a mom of two, found Edgepark, a third-party organization that partners with insurance companies, through Google. She plugged in her insurance information, picked out a Spectra 9, and that was that. “It was fully covered by insurance and the process was really easy,” she explains. “I got the pump shipped to me a few weeks later.”
Canzano adds that finding an in-network durable medical equipment (DME) breast pump provider can help parents through the process of applying for a pump. For instance, Acelleron verifies insurance information and can even request a prescription from your doctor on your behalf, so you don't have to call your insurance or your doctor. (If you already have a prescription, you’ll just upload it to the site.)
Using a third-party provider can also be helpful because you can apply for the pump at any time during your pregnancy once you have a prescription, although the company may not be able to physically ship the pump until the insurance plan approves it. For instance, you can submit your information in your second trimester so it’s done and off your to-do list, but if your insurance plan stipulates you can’t have the pump until you deliver, the company has to follow those rules.
Step 3: Be on the lookout for any specific rules.
Speaking of rules, sometimes, getting the breast pump through insurance can be as simple as filling out a form online, but it’s also important to be aware that some insurance plans may have specific rules about breast pumps. For instance, Katie Waite, who has five children, was eligible for a new pump with each pregnancy — providing they were 18 months apart — but discovered the hard way that her insurance plan also had a cruel caveat: she could not apply for the pump until after she delivered.
“When I was pregnant with my first and called my health insurance, the lady on the other end of the line told me I couldn’t order one until the baby was born, ‘just in case the baby didn’t make it,’ and well, that pretty reduced me to a puddle on the floor that week,” Waite notes. “I later called and complained and was told that this is not how I should have been told but it was the policy.”
Again, the rules for each insurance plan will vary, but Cantrell recommends contacting your insurance company for the details during your late second or third trimester. Typically, Canzano adds that most insurances cover one breast pump per pregnancy but there are some insurance and Medicaid plans that only allow one pump for a certain number of years and on a very rare occasion, only one pump per lifetime.
What brands of breast pumps are covered by insurance?
Unfortunately, some brands of breast pumps may not be covered fully by insurance, or covered at all. So if you have your eye on a specific type of pump, be sure to double check with your insurance provider if it’s covered. Alternatively, it’s worth looking into if they offer a reimbursement option you could take advantage of, like I did.
“Right now, wearable breast pumps made by Elvie and Willow are generating the most buzz despite rarely being covered by insurance due to their high price point,” Canzano says.
However, the good news is, many more affordable models of wearable breast pumps are being offered, so you may find a different option that works just as well for you. “Medela and Spectra breast pumps are probably the two most popular and known brands outside of the wearable category which make up the majority of the breast pump market,” he adds.
Other FAQs about breast pumps:
The most important step about getting a breast pump through your insurance is to check with your plan about what the coverage rules are, but there are also some other things that can be helpful to know.
How long do you have to get a pump after your baby is born?
Canzano notes that, in general, most plans allow you to apply for a pump for up to 12 months after your baby is born. Again, however, this can vary, so be sure to check.
What does Medicaid cover for breast pumps?
While most Medicaid plans throughout the country cover a breast pump, Canzano adds that there are some state Medicaid plans that did not take federal money and thus do not have to follow the ACA Preventive Health Services guidelines.
“These plans typically only cover a breast pump if there is medical necessity, meaning the baby lacks the ability to initiate breastfeeding because of a medical condition like prematurity or oral defect,” he explains. Again, you’ll have to check with your specific plan to find out the rules.
What if you don't have insurance?
Canzano explains that if you don’t have health insurance, your options are to:
- Pay out of pocket for your pump.
- Pay using a FSA or HSA card.
- Check with your WIC clinic to find out if you're eligible to rent or get a pump for free and what other services may be available to you.
- It’s not recommended that you share a breast pump that’s been used by another person; the only way this can be done safely is through an authorized provider to ensure it’s been cleaned and sterilized properly.
Chaunie Brusie is a labor and delivery nurse turned writer; she specializes in health and parenting and her work has appeared everywhere from Glamour to The New York Times to Parents magazine. Her kids mostly think she drinks coffee all day (she does) and are really, really impressed that she can "type without looking at the computer." Chaunie lives with her husband and five young kids on a small farm in Michigan, in the middle of an actual hayfield.