QUESTION: Our health plan generally requires cost-sharing for out-of-network services, but we have heard that there is a special rule for lactation services. Can our health plan require cost-sharing for lactation counseling services obtained outside the network?
ANSWER: If your plan’s network includes a lactation counseling provider, your plan may require cost-sharing for out-of-network lactation counseling services. As preventive services, prenatal and postnatal lactation support, counseling, and equipment rental must be covered without cost-sharing (subject to reasonable medical management). Although plans that have a network of providers generally are not required to cover preventive services that are provided out-of-network, participants must be able to access required preventive services from in-network providers. Thus, the agencies have advised that if a plan’s network does not include a provider who offers a particular preventive service, the plan must cover the service without cost-sharing when performed by an out-of-network provider.
A court has ruled in favor of health plan participants who filed suit seeking coverage of out-of-network lactation support and counseling services (see our Checkpoint article). Concluding that the participants had to be reimbursed for out-of-network costs when adequate in-network providers of lactation support and counseling were not available, the court explained that the law required participants to have meaningful access to comprehensive lactation support and counseling services, and that illusory or de minimis access was not sufficient.
Keep in mind that coverage of lactation counseling services without cost-sharing is only required when the provider is acting within the scope of a state license or certification (e.g., a registered nurse). In addition, plans may not limit coverage for lactation counseling without cost-sharing to inpatient services.
For more information, see EBIA’s Group Health Plan Mandates manual at Section XIV.C (“Required Preventive Health Services Coverage”), and EBIA’s Health Care Reform manual at Section XII.C.5 (“HRSA Recommendations Regarding Women’s Wellness Services”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C.1.b (“Preventive Services: Considerations for Self-Insured Health Plans”).
Contributing Editors: EBIA Staff.