In many ways the answer is YES — replacement parts can be covered under insurance, however; the specifics will depend upon the specifics of your insurance plan, the type of insurance you have, and whether or not you purchase the replacement parts through a DME supplier or an in-network provider.
Because there is no single standard rule for all insurance plans, there is a great deal of confusion surrounding this issue. The positive side of this situation is that the systems do follow a predictable sequence of events once you understand what questions to ask.
But “how much” and “how often” will vary by insurance plan
Under the Affordable Care Act (ACA) most non-grandfathered health plans are required to provide coverage for breastfeeding support and equipment, and the Department of Health and Human Services has provided federal guidance that indicates the coverage shall continue for the duration of breastfeeding. Many plans interpret “equipment and supplies” to include replacement parts for common breast pumps, but the frequency of replacement (for example, “every three months” or “as needed”) and which specific parts are included can vary.
As a result of this, it’s possible that two parents with the same insurance company could have vastly different experiences — coverage is typically determined by the specific plan design and the rules used by the contracted DME network of the insurance company’s contracted providers, rather than the insurance company’s brand name.
What parts qualify as “replacement parts” (what insurance is most likely to pay for)
When insurance plans provide coverage for breast pump supplies, they’re typically referring to the functional parts of the pump that directly affect suction, comfort, and milk collection — such items as tubing, shields/flanges, valves, membranes, adapters, caps, bottles, and related accessories. An example of a plan that clearly defines covered supply components is a Blue Cross/Blue Shield Medical Policy that lists several supply component categories as covered when obtained through an in-network provider.
Additionally, some programs require suppliers to submit claims utilizing recognized billing codes for specific replacement parts (you’ll occasionally hear references to these codes in back-end communication). Most state Medicaid programs publish specific rules outlining which pump supply code(s) can be reimbursed and under what circumstances.
Plan caveat: your plan may only cover them if you use an in-network DME or approved supplier
Many individuals who receive denials for replacement parts when they’ve attempted to obtain them from retailers that aren’t in-network for their insurance are shocked to learn that this is a common occurrence. While “covered” does indeed mean “covered,” it does not automatically mean “anywhere.” More frequently, “covered” simply means “if we agree that you followed our process,” which may involve purchasing through an approved DME provider, obtaining a prescription, or following the plan’s replacement schedule.
This is not unique to breast pumps. This is how many Durable Medical Equipment (DME) products work. To avoid potential problems, utilize the plan’s preferred method of accessing DME.
How often can you receive replacement parts through your insurance?
Insurance coverage frequency is the most variable aspect of this entire question. Some plans provide for scheduled replacement parts on a predetermined basis (i.e., 60-90 days), while other plans provide for replacement parts only when a part ceases to function properly. As an example, a Medicaid plan in Minnesota specifies that certain replacement part codes will only be reimbursed by Medicaid when the part no longer functions, and includes time restrictions based on the month the pump was acquired.
In practical terms, when your insurance plan provides for replacement parts, it will typically be either:
- Scheduled Resupply (Automatic/Periodic): Your insurance company will send replacement parts to you on a predetermined schedule.
- Replacement on Need: You will only be able to replace parts when a part fails.
TRICARE, Medicaid, and Medicare — What are the rules for these programs?
If you are dealing with TRICARE, the program provides that TRICARE will provide a free breast pump and breast pump supplies to new mothers, and outlines additional eligibility requirements on its webpage.
For Medicaid, each state has its own Medicaid program and therefore has its own Medicaid guidelines regarding what parts are covered and how they should be billed.
Medicare is a bit of a special case. Medicare generally is not considered the primary insurer for postpartum lactation equipment in the same manner that commercial plans and Medicaid programs are, and the Centers for Medicare & Medicaid Services (CMS) emphasizes that disposable supplies for lactation equipment are not easily categorized as Durable Medical Equipment (DME) within the Medicare structure (with exceptions made based on the specific item and claim-by-claim determinations). If your audience includes older caregivers or less common types of insurance coverage, it would be wise to note that Medicare has its own distinct rules that may differ from those of what people typically think.
Why replacement parts are denied (and even though, people “should” be covered)
Most of the time, denials occur because of a few main reasons. Typically, it is because the order did not go through an approved provider; therefore, the claim will be considered out-of-network or non-covered. In addition, another frequent reason for denial is because the plan contains a replacement frequency rule, and the request is made “too soon,” or the plan requires documentation of failure before making the replacement.
Another example is when the plan bundles parts with the initial pump order, and will not reimburse a separate replacement order until a certain period of time has passed (this can be seen in published Medicaid guidance).
How to determine what your plan provides
To make the process easier and less frustrating for yourself, you do not necessarily need to become an insurance expert, you simply need to ask the correct questions in the correct order.
Firstly, confirm whether your plan includes “breast pump supplies” or “replacement parts.” Additionally, confirm whether the supplies must be ordered from an in-network DME. Next, ask about the number of times per year that you are allowed to replace a piece of equipment, and if you need a prescription or prior authorization to receive approval. The Healthcare.gov guidance provides additional information for patients and also reminds patients that some plans have a requirement for prior authorization for breastfeeding equipment.
By asking these questions ahead of time, you will be able to avoid the most common “I ordered it and received a bill” surprise.
So when Should You Replace Pump Parts?
Even if your insurance company does provide coverage for replacement parts, it is still important to understand when you should replace them. One common indicator that you may need to replace the parts of your breast pump is decreased suction or increased pumping time needed to obtain the desired amount of milk, typically indicating worn-out valves/ membranes. Many educational resources provided by suppliers indicate recurring replacement of parts as a regular occurrence while pumping.
This becomes a useful transition statement in your article: “Coverage is a single question. Understanding when to replace the parts is the next.”
FAQs
Are Replacement Valves & Membranes Covered By Insurance?
Yes, usually; when your insurance plan has included ongoing breast pump supplies as a covered benefit. However, the frequency at which you are permitted to replace your breast pump parts can vary greatly, depending upon your plan’s replacement schedule.
Are Milk Storage Bags Also Included?
Some coverage guidelines and payer policies include milk storage supplies within the general breastfeeding supplies category, however this can vary greatly depending upon the specific plan or program.
Must My Baby Be On My Insurance To Get Coverage For Replacement Parts?
It all depends upon your insurance plan; however, many benefits are provided under the postpartum parent’s preventive coverage. If you are unsure, the best course of action would be to verify both your eligibility and ordering requirements with either your insurance plan directly, or with an in-network supplier.
References:
- https://www.healthcare.gov/coverage/breast-feeding-benefits/
- https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=MNDHS-066486
- https://tricare.mil/breastpumps
- https://www.hhs.gov/answers/health-insurance-reform/are-breast-pumps-covered-by-the-affordable-care-act/index.html
- https://aahomecare.org/files/galleries/Breastfeeding_Coalition_Recommended_Coverage.pdf