All About Insurance

INSURANCE AND LACTATION SERVICES

I am in-network with:

Cigna - book here through Wildflower
Aetna (all Aetna subsidiary plans except Medicaid, Allied Health, Wellnet, and GEHA)
TLN (The Lactation Network) - book here through Branchburg Lactation: If you have Blue Cross Blue Shield PPO (Horizon BCBS, Anthem BCBS and out-of-state BCBS plans), CIGNA PPO, most United plans (including UMR and Oxford) or any plan with the Multiplan or PNOA logo and Lactation Network approves you, up to 6 visits are covered 100% with more potentially available with approval. If you have one of the aforementioned insurance carriers, please book an appointment here first, You will receive a message on your confirmation page guiding you to go to Lactation Network's website to complete the insurance information to confirm your coverage.
If you are not covered by Aetna, Cigna, and did not receive coverage approval from Lactation Network, you will need to pay out of pocket for your appointment. I will provide proper documentation for you to seek reimbursement from your plan. Please contact your carrier directly for details. In many cases, the cost of a consultation can be applied to a Health Care Spending Account as well (HSA or FSA accounts).
All services are 50% off for parents who are enrolled in WIC, SNAP, TANF, or who are Medicaid eligible or are unemployed. I do a limited amounts of discounts or pro bono consults for cases of financial need. Please reach out to discuss your eligibility and how I can support you.

Other fees: If you live outside of my service area (see bottom of page), a long-distance travel fee of $1.25/minute beyond a 40-minute roundtrip from Maplewood, NJ may apply.

If you don't have any of the above plans, you can pay out of pocket and receive a superbill to submit to your insurance for reimbursement.

What your insurance company doesn't want you to know

Some background:

Per the the Affordable Care Act (ACA), insurance companies are required to cover out-of-network lactation visits.

Coverage for Lactation Services: Under the ACA, most health insurance plans are required to cover lactation counseling and breastfeeding equipment. This includes support from a lactation consultant and the provision of breastfeeding supplies, such as breast pumps, at no additional cost to you.
Lactation Counseling: Lactation counseling services are covered by insurance plans as specified by the ACA, and we will work with your insurance provider to ensure coverage.
Breastfeeding Equipment: Breast pumps and other necessary breastfeeding equipment are covered by the ACA. I can help you navigate the process of obtaining these items through your insurance plan.
Insurance Verification: I recommend verifying your lactation services coverage with your insurance provider before your appointment. I'm happy to assist with this process and provide any necessary documentation to ensure your services are covered.
No-Cost to You: As mandated by the ACA, there should be no additional cost to you for lactation counseling or breastfeeding equipment. If you encounter any issues or unexpected costs, please contact me for assistance.
I respect your privacy and will handle all personal and health information confidentially, in compliance with HIPAA regulations.Privacy and Confidentiality: I

According to the National Women's Law Center's Toolkit: If your insurance company doesn’t have any lactation consultants or breast pump providers in-network, the insurance company must cover services from an out-of-network provider without cost-sharing. Federal guidance makes clear that “if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.” If your insurance company does not have providers in its network to provide breastfeeding equipment or lactation counseling, you must be able to go out-of-network, the item or service must be covered, and covered at no cost-sharing.

Getting an exemption:
If they tell you they won't cover a visit, you should request a network (or gap) exemption for at least 2-4 visits.

Here is the information they will need:

Provider: Danielle Tropea
NPI: 1164874004
EIN: 99-3977620
CAQH: 15169284
IBCLC certification #: L-84572
Phone: 973-310-2884
Codes most likely used:
Diagnosis Code z39.1
Procedure Code 99404, s9443, 99204
Please make sure to keep the name of the representative you spoke with and get a reference number.

At the conclusion of our consultation and paying my fee, I will provide you with a superbill, which serves as a statement and receipt. You will then submit it along with any necessary claim forms to your insurer. I will include travel and parking fees to the superbill.

MOST of the time, insurers will reimburse the claim with no issue. Occasionally, they may deny the claim, so it's important to find out why. Sometimes it needs to be submitted under the baby's insurance instead of the mother's or a referral from your pediatrician or OB/GYN is needed. Other times, they are only willing to reimburse under different codes. Let me know, and I will provide you with an updated superbill.

United Healthcare says they cover lactation care but they have refused every procedure code I have ever used.

If they still refuse, you can use this letter to appeal.

Federal law:

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act), insurers are required to cover breastfeeding support, supplies, and counseling. The exact language is "The Women's Preventive Services Initiative recommends comprehensive lactation support services (including counseling, education, and breastfeeding equipment and supplies) during the antenatal, perinatal, and the postpartum period to ensure the successful initiation and maintenance of breastfeeding."

In New Jersey:

New Jersey law requires "health insurers... to provide coverage without requiring any cost-sharing, for expenses incurred in the provision of breastfeeding support and counseling before or after the birth of an infant and the provision of a breast pump."

Please file a complaint via the New Jersey Department of Banking and Insurance if they refuse to reimburse you.