Can You Get a Second Breast Pump Through Insurance?

Navigating health insurance coverage for a breast pump is a common consideration for many new parents. While the Affordable Care Act (ACA) generally mandates that most health insurance plans cover breastfeeding support, counseling, and equipment, the specifics of this coverage, particularly for a second breast pump, can vary significantly. Understanding your policy’s nuances is key to determining eligibility and the process for obtaining equipment.

Circumstances for Additional Coverage

Obtaining coverage for a second breast pump often depends on specific circumstances recognized by your insurance provider. One primary reason for additional coverage is medical necessity, which requires documentation from a healthcare provider. This can include situations where an infant has a medical condition requiring specialized feeding, or if a parent experiences issues like insufficient milk supply that necessitate a hospital-grade pump.

Another common scenario involves a change in medical needs, such as transitioning from a manual pump to a more powerful electric pump due to increased pumping frequency or greater efficiency. If a previously covered pump malfunctions or is irreparably damaged, insurance may consider coverage for a replacement. Many insurance policies also reset eligibility for a new breast pump with each subsequent pregnancy.

Understanding Your Insurance Plan

Before seeking a second breast pump, it is important to thoroughly review your health insurance policy documents. Key documents to examine include the Summary of Benefits and Coverage (SBC) and any detailed plan descriptions, which outline what services and equipment are covered. These documents often specify whether multiple pumps are covered, under what conditions, and if there are limitations on the type (e.g., manual, standard electric, or hospital-grade) or quantity.

Breast pumps are classified as Durable Medical Equipment (DME), meaning specific rules for acquisition and coverage apply. Verify if your plan requires an in-network DME supplier, as purchasing from an out-of-network provider may result in no coverage or higher out-of-pocket costs. Understanding prescription requirements is crucial; plans require a prescription from a healthcare provider that specifies medical necessity. Contacting your insurance provider directly can clarify any ambiguities.

Acquiring a Second Breast Pump

Once you have gathered the necessary documentation, including a prescription from your healthcare provider, you can begin acquiring a second breast pump. Work with an in-network Durable Medical Equipment (DME) supplier. This supplier will handle billing directly with your insurance company, requiring your prescription and any other requested information.

The supplier will verify your benefits and process the order, which may involve a waiting period of several days to weeks for delivery, depending on the supplier and product availability. If your claim for a second pump is initially denied, you have the right to appeal. This involves submitting a written appeal letter to your insurance company, outlining why the pump is medically necessary and providing supporting documentation from your healthcare provider. Your healthcare provider’s office can assist by providing a letter of medical necessity or resubmitting the claim with corrected information.