The Affordable Care Act mandates that most health plans must provide "breastfeeding support, supplies and counseling".
818Breastfeeds does not endorse any one type of pump or DME provider. We just try to connect you to resources that may be helpful.
ACCESSING THIS BENEFIT:
Breast pumps are called DME or Durable Medical Equipment. Generally "pharmacy" or a DME provider is contracted by the Health Plan to provide this benefit. Your physician generally must give you a prescription for this benefit. Most health plan contracts (that are not grandfathered) have set up contracts with the DME providers below.
Watch a presentation on how to Access Medi-Cal Benefits - HERE
E0604 - Hospital grade breast pumps induce and bring in a milk supply. They are critical at the beginning of breastfeeding when milk supply is being established, if the baby isn't latching or there are underlying medical conditions. Not all mothers need this benefit.
E0603 - Personal use breast pumps maintain a well-established milk supply. For temporary separation, like for work.
E0602 - Manual breast pump - to relieve temporary engorgement or for a brief separation (less than 3 hours.)
If your physician says that you need a "hospital grade breast pump" most health plans will only reimburse based on "Daily Rental". The going rate is between $3-7 per day.
The State of California has a law that has directed the Medi-Cal Benefits department to "streamline and simplify existing Medi-Cal program procedures in order to improve access to lactation supports and breast pumps among Medi-Cal recipients"
Further, all Medi-Cal contracts are governed by this policy that mandates coverage of lactation aids and breastfeeding support.
In the case of MediCal Managed Care (MMC), this responsibility may be delegated to the provider or Independent Physician Association (IPA) which is contracted to provide services. Most DME contracts for MMC are with Western Drug or Apria in LA County, and they have confirmed access to Hospital Grade Breast Pumps (E0604), however their personal use breast pumps, may be insufficient. Contact to determine if it is a quality pump.
For "straight" Medi-Cal (aka presumptive eligibility, fee for service) the provider gives a prescription and the patient takes it to a participating DME supplier. See below for known local providers. There are currently, NO KNOWN providers of Hospital Grade Breast Pumps (E0604) for the Straight Medi-CAL population in LA County, with the exception of "Comfort Care Pharmacy" which has limited stock.
There is NO requirement for a "Treatment Authorization Request" or TAR, nor medical documentation, UNTIL the cost of the pump benefit exceeds
$164 / in a 15 month period for E0604 - Hospital Grade Breast Pump
$100 / in a calendar month for E0603 - Personal Use Breast Pump
Ultimately it is your physician's responsibility to prescribe the pump and help get it for you.
What if I can't get a pump? You can complain:
DMHC - This is the link to the Department of Managed Health Care. They regulate health plans.
DFEH - This is the link to the Department of Fair Employment and Housing - which enforces the Unruh Civil Rights Act. File a sex discrimination complaint against your health plan for failing to provide equal services for breastfeeding women.
You may qualify for WIC and their pump program! Learn more here.