Mac Lactation

We are in-network with [insert insurance here]. Upon submitting the intake form, we will verify your benefits and notify you if we cannot accept your insurance or if there may be any out of pocket. Scroll down for payer-specific information, including how to call and check your benefits.

Up-to-date fee information is available in the online booking widget.

If you would like to call your insurance to request an out-of-network exception, you can give them this information:

• NPI: XXXX
• EIN: XXXX
• Code S9443, billed amount $XXX

We will provide you with a superbill with code S9443 under the lactating parent that includes the insurance information you provide to us. We cannot guarantee that your insurance will reimburse you under the Affordable Care Act.

[Include this if you charge a home visit fee]

If you would like a home visit, you will pay a convenience fee of $75 for each visit. The home visit convenience fee is non-refundable if you cancel with less than 24 hours’ notice. This fee is not eligible for insurance reimbursement. The self-pay fee includes the home visit fee.

Sliding scale may be available if you or your partner(s) meet one of these qualifications: [add your policy here]

Please contact us prior to booking to request sliding scale for the self-pay rate or waiver of the home visit convenience fee.

We cannot waive cost-sharing for our in-network clients even on a sliding scale basis (unfortunately this is considered insurance fraud and we don’t do that).

We cannot guarantee that your covered services will not have cost-sharing applied by your insurance. Even if your insurance told you that you have full coverage for lactation care, there will likely be limitations and restrictions on care that may differ from plan to plan. We cannot legally or contractually waive the cost-sharing under any circumstance. We are required by law to invoice you.

[Add your follow up policies here.]

We submit a claim for you and for your baby (when present). That is two separate claims for two separate people. You and your baby do NOT need to be on the same insurance for services to be rendered.

If one of you is out-of-network, we will still submit an out-of-network claim to the insurance in the hopes that they will pay something.

Once both of your claims have been processed, we will balance bill you for any amount not covered by either insurance up to our listed self pay fee for the type of visit you had. We will never charge you any amount that would cause us to collect more than our stated self pay fee from you and your insurance combined.

Example 1: The self pay fee for the service is listed as $200. We bill each insurance $200. Your in-network insurance pays $100. Your baby’s out-of-network insurance pays $10. You would be balanced billed $90.

Example 2: The self pay fee for the service is listed as $200. We bill each insurance $200. Your baby’s in-network insurance pays $100. Your out-of-network insurance pays $200. You would not be billed anything.

Aetna

[If you take Aetna, you can use this wording.]

We are in-network with Aetna and most of its subsidiaries. 

You can call Member Services and ask if we are in-network using this information: NPI XXXX and EIN XXXX. 

Aetna may have told you that you would get up to 6 “free” lactation sessions. They probably did not also explain to you that they place strict limitations on what those free sessions actually include. 

This is going to get a little technical, so bear with me. 

There is a code called S9443 which covers a lactation session by a non-physician provider. Aetna gives you 6 uses of this code that can be used for you and/or your baby. Services that we offer which are fully covered by this code include:

• Virtual prenatal 
• Virtual check in for existing clients
• In office prenatal
• In office flange fitting

In order to provide comprehensive lactation care for you and your baby, we bill S9443 for you and for your baby. The reason we bill S9443 for both you and your baby is because it will not count to anyone’s deductible. It allows us to receive payment and minimize or even eliminate potential out-of-pocket costs to you. 

But since you only get 6 uses of S9443, that code does run out. After six uses of this code, Aetna will tell you that S9443 is now “patient responsibility.” You will be responsible for any amount applied to your deductible, and balance billed up to our published self pay rate for the type of appointment you had on that date of service (initial, follow up, or prenatal, in office, home, or virtually). 

If you saw another lactation consultant before seeing us, or if you took a class from the company that sent you your breast pump, you may have already used up some of your S9443 benefit. We cannot see how many you have left.

In addition, we bill time-based codes that cover the additional time required to provide comprehensive care. If you have not met your deductible, the time-based code we bill for your baby will go to your deductible. If you have a specialist copay, it may apply to your baby’s claim. You will be invoiced for cost-sharing and your card on file will be billed. 

S9443 is the only code we can bill for virtual visits, so once it is maxed out or if your plan does not cover S9443, you will pay our published self pay rate for virtual visits.

On request, we can provide you with our best estimate of what cost-sharing or out-of-pocket for you or your baby might be. 

Anthem BCBS

[If you take Anthem, you can use this wording.]

You can call Member Services and ask if we are in-network using this information: NPI XXX and EIN XXX. 

​Each and every Anthem plan has different preventive care guidelines. Some of these are published and freely available to us. Others are not available to us at all. The Anthem system only tells us if you have active coverage. They do not tell us if there are any limitations in place on your plan. We recommend you call your plan and ask if your plan covers preventive care and lactation, specifically codes S9443 and 99404.

CIGNA

We are in-network with CIGNA and can bill them directly. There is typically no out-of-pocket for you or limitations on the number of times you can see us.

You can call Member Services and ask if we are in-network using this information: NPI XXX and EIN XXX. 

United Healthcare

We are in-network with commercial plans. There are typically no limitations on the number of times you can see us and there is typically no out-of-pocket for you or your baby.

You can call Member Services and ask if we are in-network using this information: NPI XXX and EIN XXX.