Wednesday, January 9, 2013

Aetna Breast Pump coverage under Affordable Healthcare Act

As my sister likes to say, "thanks to Obamacare, being a woman is no longer a pre-existing condition." Regardless of your political stance, it's nice that things like contraception and breast pumps are now mandatory to be covered under insurance policies without any copay (apparently some are grandfathered in/out, so check your policy).

There isn't a lot of info out there, so I thought I'd share what I've learned from talking to the insurance company - I have Aetna - and the medical equipment provider.

I spoke with Aetna this week. I am due 2/9/13, and pumps are covered as long as they are purchased via a durable medical equipment provider within 60 days following the baby's birth. You can find the suppliers via their DocFind website. Many of the providers I found do not carry the same brands we're familiar with commercially at Target, BRU, etc, -- only the hospital grade brands. However, Sunmed Medical carries Medela.

After talking to Sunmed (they are very helpful at navigating the process thus far!), here's what I learned:
  • Can't order the pump until the baby is born, but they can provide you with paperwork that can be done ahead of time. Then, when you go into labor, give them a call and they'll get the order processed ASAP so that you have it within a few days of coming home.
  • They don't currently have an arrangement to cover additional supplies (bottles, shields, nipples, etc), but that could change as they continue negotiations with the insurance providers.
  • There are two pump options (see below).

Breast pumps are covered under the new Affordability Health Care Act.  Two items must have occurred to qualify under this new provision:
1.  Renewal date of qualifying* plans must have occurred AFTER 8/1/12 and prior to the birth of the baby.  Most plans renew January 1.  Please check with your employer to be sure.  Not sure? If you submit your information to us, we will check this as well.
2.  Birth of baby must have occurred within 60 days of the receipt of the pump.
For example, if your plan renews 1/1/13 and the due date is 5/15/13, you would qualify, and we would just get the verification in place now.  Once you deliver, just let us know the baby has delivered, and we will ship you the pump.  If your baby is due 5/15/13, and your plan doesn't renew until 7/20/13, you would NOT qualify, since your 60 day window would have passed from the time of delivery to the time the plan becomes eligible under the affordable health care act.
If you meet the qualifications above, the pump will be covered at 100% with no deductible or co-pay involved.  If you do not meet the qualifications above, the pump may be covered under your medical policy, with all of the coverage criteria, deductibles and co-pays of your health plan.  We can also help sort through those details as well.

There are two pumps that are eligible through this provider. With my personal insurance plan, I can pay $125 out of pocket to get the Medela Freestyle (vs the retail price of $350-$400!).

We carry only Medelea products, the most highly regarded breast pump technology in the world. They have developed the Medela Advanced Personal Double Pump (APDP), designed for the specific needs of the Affordability Health Care Act and Insurance recipients, which is substantially equivalent to the Medela Pump in Style, their retail product available at Target, Toys R Us, etc.  
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[Medela Advanced Personal Double Pump]

The APDP has the same motor as the Pump in Style, but comes with more accessories than the Pump In Style, including a manual pump for emergency situations.  The Sunmed version of the APDP also comes with a battery pack.  Just insert batteries in the event pumping needs to occur away from an electric outlet.
[Medela Freestyle]
The Medela Freestyle is available as an option, however, an additional cost would need to be paid by the recipient, and not the insurance company.  If this option is your choice, please contact us and we can provide you that exact additional cost.  Generally, it is about $150.00 additional, depending on your Insurance carrier.

So, now what? Basically, you complete a form so they can begin the fulfillment process. If you can get your physician to write you a prescription for the pump, it may make the process move more quickly, but it isn't required. The form is pretty simple info - contact info, insurance provider info, and doctor's contact info.

To get started, you would provide us your demographics and physician information and we can start the process.  If you already have a signed prescription, please fax it to us, along with providing us the demographic information below.
If you prefer, you can call us at 800-714-7434 M-F between 9 am and 5pm EST, and we can answer any additional questions you may have, and we can take your information over the phone.  Or, provide us your contact information and we can call you. 

1.    Complete the form and email or fax it back to us at 800-715-5422, or call us with this same information

2.    We will verify your benefits and eligibility

3.    We will notify you of the information and coverage

4.    We will hold this information ready to go for shipment of your breast pump

5.    Upon delivery, notify us of the delivery date, and we will ship the pump to you.(Insurance company requires birth of child to occur prior to shipment of the pump)
            6.    Delivery is ground via UPS from Chicago, and should arrive within 7 days.

This is what I've learned thus far, so hopefully it'll help some of you mamas out there, too. I'm planning to get my paperwork submitted this week, and (crossing my fingers) it should be as easy as a phone call when I go into labor for the pump to magically arrive on the doorstep.

Of course, coverage & options may vary with each insurer and their approved medical suppliers. It's not too much hassle to save several hundred dollars, so that's a relief! You just never know with insurance sometimes!

**update 1/24/13: as luck would have it, my plan is actually "grandfathered OUT" of the Affordable Healthcare Act policies, so this process doesn't actually apply. Unfortunately, I won't be able to let you know how quickly the pump ships, works, etc. Instead, I just get to pay higher healthcare premiums without the benefit everyone else in the country receives. BUT...hopefully this info will come in handy for some of you. If not, check out the best price I found on a Medela Freestyle breast pump here.**


  1. This is exactly the info I was looking for -- sorry to heard that it turned out not to apply in your situation!

    BTW my beagle's face is very similar to Lula's :)

  2. Thanks for all the information! We're trying to figure this reimbursable pump process out in preparation for our Fall baby :)

    Hope all is well.

  3. Thanks for providing this information. I have had the hardest time figuring out what the difference between the Medela that Byron Healthcare offers and the Medela Pump in Style offered at retail stores. Sounds like it's pretty similar!

  4. Im so aetna plan is also not qualified for a pump to be covered. Hope all people enjoy reaping the benefits of my high premium. Ive got to move. Thanks, Aetna and Obama.

  5. Its covered under mine but the instructions state that it can be ordered 30 days before the birth of the baby

  6. I came across this and I find It truly helpful & it helped me out a lot. I hope to offer
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  7. In the past few years, having a baby requires the mother to spend most of her time at home breastfeeding her child. However, it negatively impacted their finances because of not being employed. This was changed as the freestyle breast pump was introduced in the market.