Can I Get a Second Breast Pump Through Secondary Insurance?

In the United States, the Affordable Care Act (ACA) mandates that most health insurance plans cover the cost of a breast pump, often with no out-of-pocket expenses. This provision has significantly improved access to essential equipment for new and expecting parents. While primary insurance typically covers one breast pump per pregnancy, many individuals wonder if a second breast pump can be obtained through secondary insurance.

Eligibility for a Second Pump

Most insurance plans generally cover one breast pump per pregnancy. However, circumstances may arise where an additional pump is considered for coverage. This can include a new pregnancy, allowing for updated equipment with each child. Coverage for a second pump might also be considered due to medical necessity, such as having a baby in the Neonatal Intensive Care Unit (NICU), a multiple birth, or experiencing medical conditions like mastitis or persistent low milk supply that require more intensive pumping support.

Some policies may also allow for a second pump if the initial one malfunctions and is no longer effective, or if the first pump was purchased out-of-pocket before coverage was realized. While some insurance plans might offer a new pump annually or every few years, or cover both a manual and an electric pump, a second pump through insurance is not guaranteed. Eligibility depends on the specific terms and conditions outlined within an individual’s health insurance policy.

Navigating Secondary Insurance Policies

When an individual has both primary and secondary health insurance, a process called coordination of benefits (COB) determines which plan pays first. The primary insurance plan pays its portion of the claim first, and then the secondary insurance plan may cover some or all of the remaining balance, including deductibles, co-payments, or services not fully covered by the primary plan. For durable medical equipment (DME), such as breast pumps, secondary insurance typically functions as a supplement to the primary coverage.

It is important to review the secondary insurance policy details to understand its specific provisions for DME coverage. Policies may have their own limits on benefits, approved suppliers, or requirements for medical necessity. While some sources suggest secondary insurance might independently qualify for a breast pump, most often, it will only provide coverage if the primary plan has processed the claim and either paid a portion or denied it. Individuals should contact their secondary insurance provider directly to inquire about their COB clauses and any specific coverage rules for additional breast pumps.

Required Documentation and Information

Before contacting a secondary insurance provider or submitting a claim, gathering specific documentation and information is essential. A medical prescription or order from a healthcare provider is almost always required for a breast pump, even if it is a second one. This prescription should clearly state the medical necessity for an additional pump, including any relevant diagnosis codes that support the need.

It is necessary to have both the primary and secondary insurance policy numbers and group identification readily available. Information regarding the first breast pump obtained, such as the date it was received, the supplier, and details of the primary insurance claim, may also be required for coordination of benefits. Any supporting medical records, such as notes from a lactation consultant or a letter from a pediatrician, can help substantiate the medical necessity for a second pump.

The Claim and Reimbursement Process

Once all necessary documentation has been prepared, the process of submitting a claim to secondary insurance can begin. It is important that the claim for the first breast pump has already been processed by the primary insurance. The secondary insurance claim typically requires an Explanation of Benefits (EOB) from the primary insurer, which details what the primary plan covered or denied. This EOB confirms the primary payment and the remaining balance.

Claims can often be submitted through the insurance provider’s online portal or by mail. The secondary claim form must accurately reflect the primary insurance payment details. After submission, it is advisable to track the claim’s progress and be prepared for potential processing times that can range from a few weeks to several months. While most claims are processed smoothly, a denial may occur if the secondary insurance determines the service is not covered or if there are discrepancies in the documentation. In such cases, understanding the specific reason for denial and initiating an appeal, if appropriate, becomes the next step.