Lactation Coverage for BCBS of Texas in Houston and San Antonio

To keep providing our services, we need to submit insurance claims for both the parent and the baby each time they visit. This is necessary because most insurance plans don't fully cover claims that only include the parent. The Affordable Care Act says insurers must cover lactation services for the lactating parent without any out-of-pocket costs, unless the plan is old (grandfathered). Please be advised that BCBS (Blue Cross Blue Shield) does not allow separate billing for both mother and baby on the same date of service. According to BCBS policy, the mother and baby are considered a single patient, and only one claim can be submitted per session.

Additionally, BCBS offers one of the lowest reimbursement rates among insurance providers, which does not adequately cover the cost of the services we provide.
As a result of this policy, a separate fee will be charged for the baby’s visit unless the baby is covered under a different insurance policy than the mother’s.

This decision was forced by the new limitations set by BCBS, not by our desire to serve you less.

Here’s when you might have to pay extra:

• If we can't bill an insurer for either the parent or baby, you’ll need to pay a PAYMENT GAP FEE: estimated $91 up to $119 on their claims.
• Depending on your insurance plan, you might also pay extra if it:
  • Doesn't allow us to claim for both the parent and child on the same day.
  • Doesn't cover lactation visits billed to the baby's plan.
  • Puts a cap on the number of visits and you've used them all up for either the baby or the parent.
  • Adds copays, coinsurance, or deductibles to the baby’s claim.
  • Isn't in-network with the baby’s insurer.

If your insurance covers the baby, the charge for their part of the visit will usually be between $91 to $119, depending on your plan.

BCBS of Texas customers should expect to have up to $119 per visit PAYMENT GAP FEE on their baby's claim.

Some BCBS plans require a referral. Please contact your member services to ask if the following CPT codes S9443 and 98960 are covered under your policy at 100% under preventative services with no referral required.
If your policy requires a referral please contact your PCP with the codes listed above with the diagnosis code Z39.1 faxed to 281-572-0627.

BCBS Home Visits: BCBS applies the entire billed amount of the home visit codes to patient responsibility. If you choose to use your BCBS insurance for a home visit be aware they apply the entire amount to patient responsibility and this amount is $375 ($425 twins). You can expect BCBS to apply to patient responsibility and we will bill this amount to the card on file for each home visit. Our discounted self pay rate is significantly less at $295 with travel fee included. If you would rather be self pay for your home visit we will send you our self pay election form for your signature.

BCBS of Texas customers should expect to have up to $119 per visit PAYMENT GAP FEE on their baby's claim.

BCBS PPO plans do not require referrals for our services however we kindly ask you to call BCBS and ask the following questions to ensure your understanding of your benefits. 

1. Is your plan grandfathered (Non ACA compliant)? 
2. Does your plan have lactation benefits? 
3. Does your plan limit lactation coverage to physicians, nurse practitioners, and midwives? 

**If any of these circumstances apply to your claims and they are denied for coverage, you will be billed at our discounted cash pay rate**

We require that all patients have a valid card on file to secure the booking of their initial visit. We will not schedule your appointment without having a valid card on file. 

* You are authorizing us to save the card on file and use it to process the following fees: 

• Late cancellation / no show fees
• Home Visit Travel Fee
• Copay/ Coinsurance / Deductible
• Non covered / denied services
• Non covered patient fee for mom or baby who does not have billable insurance