Can I Get a Second Breast Pump Through Insurance?

The Affordable Care Act (ACA) generally mandates that most health insurance plans cover breastfeeding support, counseling, and equipment, including breast pumps, as a preventive service. While many plans cover one breast pump per pregnancy, specific circumstances may allow for coverage of a second pump.

Criteria for Insurance Coverage of a Second Pump

Insurance plans typically cover one breast pump per pregnancy, ensuring parents have the necessary equipment for each new child. For subsequent pregnancies, maternity benefits often reset, allowing for a new pump for each birth. The frequency for new pump coverage can vary by insurer, with some plans allowing a new pump every year or every few years, regardless of a new pregnancy.

A second breast pump may be covered if there is a demonstrated medical necessity. This includes scenarios like a significant decrease in milk supply, the premature birth of an infant, or the birth of multiples. Specific medical conditions affecting either the parent or the baby, which make effective breastfeeding or milk expression challenging with the initial pump, can also justify a second pump. For instance, if a standard electric pump was initially provided but issues arise requiring a hospital-grade pump, documentation from a healthcare provider can support this need.

Coverage may also extend to replacing a broken or malfunctioning pump. Some plans might allow for an upgrade or a different type of pump if the initial one proves unsuitable for the parent’s specific needs, such as moving from a manual to an electric pump, or from a personal-use electric pump to a hospital-grade rental for temporary medical reasons.

Required Documentation and Claiming Process

To determine eligibility for a second breast pump, review your specific insurance policy details. This can be done by calling the member services number on your insurance card, checking your online member portal, or consulting your benefits handbook. Understanding your plan’s Durable Medical Equipment (DME) coverage for breast pumps is a necessary first step.

A prescription or letter of medical necessity from a healthcare provider, such as a doctor or lactation consultant, is typically required for a second pump. This document should include a diagnosis code and a recommendation for the specific pump type or medical reason. For example, if a hospital-grade pump is needed, the prescription might specify a procedure code like E0604, while a standard personal-use pump might use E0603. The healthcare provider’s notes often contain supporting documentation that substantiates the medical necessity of the prescribed items.

After obtaining documentation, contact your insurance company or a Durable Medical Equipment (DME) supplier directly. Many insurers partner with specific DME suppliers for breast pump distribution. These suppliers verify benefits, process claims, and deliver equipment. Submit the prescription and insurance information to the insurer or DME supplier. Follow up to confirm receipt, inquire about processing times, and address any requests for additional information to ensure a smooth approval and delivery process.

Understanding Coverage Details and Limitations

Insurance coverage varies by pump type. Most plans cover a standard electric pump, which is suitable for personal use. Manual pumps may also be covered, and a hospital-grade pump rental might be approved if medically necessary. Conditions for hospital-grade pump coverage often include specific medical justifications like a premature infant or issues with milk supply.

Coverage extends beyond the pump to include essential accessories and supplies. This often encompasses items like tubing, flanges, and milk collection bottles. The frequency for replacing these parts varies by plan, with some allowing replacements every few months or annually to maintain pump efficiency. While some plans may cover recurring supplies like milk storage bags, it is crucial to verify these details with your specific insurer.

To maximize coverage and minimize out-of-pocket expenses, use in-network Durable Medical Equipment (DME) suppliers. Using an out-of-network provider could result in higher costs or no coverage. Even with covered benefits, financial responsibilities such as deductibles, co-pays, or co-insurance may apply. While the ACA mandates coverage without co-payment for preventive services, some plans may still have cost-sharing requirements.