The real story behind Aetna's "6 covered" lactation visits!

Not all visits may be completely free.

 

Here's a breakdown:

​

• Aetna's "6 fully covered" visits are limited:

  • The 6 "covered" entities counted by Aetna are for ONE billing code (S9443), covering only about 1/4 of my total fee.

• Lactation visits are lengthy and involve multiple patients:

  • Each visit typically lasts around 1.5-2 hours and involves both the lactating parent and the baby (or babies in the case of multiples), which means additional codes are needed to represent comprehensive care. For example, a 2-hour visit uses codes 99404, S9443 (and sometimes 96161) for the parent, and 99404, S9443 for the baby.

• Potential reduction in coverage:

  • Some policies may count each use of the S9443 code (in the example above - one for parent, one for baby) as a separate visit, effectively reducing full coverage from 6 to 3 visits. (The visits are still partially covered though!)

• Baby's coverage varies:

  • The Affordable Care Act (ACA) covers lactation as preventative care for the parent, but coverage for baby varies among insurance policies - some paying in full for the baby, while others trigger deductibles, co-pays, or co-insurance.

  • New Aetna coding changes (March 2024) mean it’s more likely that there will be some out-of-pocket expense for baby.

• Factors that result in additional charges:

  • Having taken online lactation classes or previous lactation visits (even prenatal ones offered by Aeroflow and other companies that help get pumps through insurance) likely billed the S9443 code each time - reducing your remaining number of covered visits.

  • If only the parent has in-network insurance, or the visit is solely for the parent, additional charges will apply.

  • HMO plans may require referrals from both the parent's and baby's healthcare providers for full coverage.

  • Certain plans, like the Princeton Student plan or NJ hospital-based plans, may deny specific codes normally covered by Aetna.

• Take action:

  • Contact your insurance company to advocate for more coverage. For example, most people are completely unaware that companies like Aeroflow (and others) used up coverage for their prenatal classes. You have the right to ask for those claims to be reversed, especially if you were unaware that they were used!

  • Customer service representatives may initially state that the claims were coded incorrectly, but be firm and reference the information provided here (and at the top of the page).

  • Ask for a health concierge to help you (many polices provide them - ask member services). They help navigate appeals, and work with both you and the provider at the same time.

  • If necessary, escalate your call to a supervisor to support your case.

For each visit, I will submit the claim and - if claims are not covered as they should be - can sometimes do an appeal. Any fees that are not covered will be billed for using your credit card on file.