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When calling Aetna, many clients are told by representatives that they will receive 100% coverage for lactation consultations (usually 6, but this number varies with different plans). After working with Aetna for many years, I have found this may not be true for ALL clients due to some fine prints and variations in specific plans that are carried. These are some questions you may have regarding your Aetna coverage:

1.    Are you In-Network with Aetna?

    Yes. I am an In-Network provider contracted with Aetna. This means I will submit claims directly to Aetna for our lactation consultations. There are certain other insurance companies that are allied with or subsidiaries of Aetna and I may be considered In-Network with them as well. Some examples of these insurance companies include GEHA, WellNet, Meritain, Allied, etc. If I am In-Network with your carrier, you should see my name (Nancy Tsen) as a provider in your In-Network directory. If you are calling insurance to verify, you may need my NPI number: 1992219869.

2.    Will my visits be 100% covered?

    This varies. Per the Affordable Care Act of 2012 (ACA), insurance companies are to provide coverage for lactation services as part of preventative care (see the NWLC Breastfeeding Toolkit for more information). However, for insurance companies,  lactation services are only associated with the lactating parent when approving coverage and thus coverage may not extend to your baby when claims are submitted. If your Aetna plan includes deductibles, copays, and/or coinsurances (a.k.a. “costsharing”), then there will likely be some amount due Out-of-Pocket after claims are processed for your baby. Insurance claims are submitted according to the time spent and services rendered for each patient being assessed and evaluated at a consultation. My contract with Aetna states that I am obligated to bill you for any amounts they apply to “patient responsibility”. As a courtesy to any Aetna clients that schedule a consultation, I try to provide an estimate of amounts that could be due for our visits to help with financial consideration before our visit and prevent any surprise bills later (if this information is available).

3.    Am I covered for 6 visits?

    Insurance language can get confusing and a bit misleading. “6 Visits” in insurance language actually means “6 Procedure Codes” that they allow for lactation coverage (according to Aetna’s “Benefit Guidance Statement” a.k.a. "BGS"). Each consultation uses 2 Procedure Codes for the lactating parent. Therefore - if you do the math, the parent really only gets 3 physical visits that are 100% covered (IF no other lactation-related education/classes used lactation codes prior to our visits). For the baby, “6 Procedure Codes” will apply, but they only allow lactation coverage for 1 code at each physical visit (according to BGS). Costsharing (see above at Question #2) will be processed to the other code, if applicable according to the specific plan and benefits. This is what I have seen in my experience with Aetna over and over again in the years I have been with them.

I am unable to know exactly how many “Lactation Codes” are part of a specific plan (6 is usual, but some plans have an unlimited number). Some companies (usually those that sell breast pumps) that offer “free” online lactation classes  actually bill your insurance for payment, and don’t explain they’re using up your lactation codes. You may be able to find out how many codes are left by calling Aetna and asking “How many lactation codes are allowed on my plan and how many are left according to my lactation accumulator?”. Please document the name of the representative and reference # for your own records in case of any discrepancies in the future. 


4.    Will I need to pay anything at the time of our visit?


    Being In-Network with Aetna means I will submit claims directly to Aetna after our visits. Any payments needed at the time of our visit is likely due to the “Long Distance Fee” (if applicable), any Out-of-Network fees for you or baby (if applicable), and/or any balances you may want to pay in person. A credit card is required to be kept on your file in case of any balances not paid after 30 days (you will receive a Payment Policy Consent Form for more detailed information) - but this card is not charged for any other reason and not without notice.


5.    My baby has coverage under my plan and my partner’s plan at the same time so how does this affect coverage for our lactation consultation?


    There is something called “The Birthday Rule” that exists in insurance land and it is something they use to help determine which plan is supposed to cover for baby’s care. Unfortunately, I have no way to view this for you. You will need to find out which insurance is the baby’s Primary Insurance. If Aetna is not the baby’s primary insurance, Out-of-Network fees will be due at the time of our visit for the baby’s portion of the consultations. You will be given a “Superbill” to submit to the insurance company to seek reimbursement from them (if applicable according to your plan coverage and benefits). Sometimes, if that Non-Aetna Primary Insurance denies coverage of a submitted claim, a copy of that denial may be sent to Aetna (under the circumstance that Aetna is the secondary insurance) to seek additional coverage. 


6.    If my claims seem like they are processed incorrectly, what can I do?


    I will typically resubmit claims at least once if there seems to be a denial that was not warranted or coverage appears odd according to your specific plan. You will also receive an Explanation of Benefits (EOBs) from Aetna for each of our dates of service for each patient to see how your claims were processed. I usually recommend clients also contact Aetna themselves if the claim seems to be processed incorrectly so that this may give them more reason to reconsider the coverage.

I hope these answers help you to better understand how Aetna covers lactation consultations. I would be more than happy to answer any questions you may have that were not addressed here regarding your lactation coverage.

Please feel free to contact me:

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