Policies for clients with Aetna Insurance

Bayou City Breastfeeding
Is Bayou City Breastfeeding an in-network provider?

We have IBCLCs who are in-network providers for most Aetna plans, except for Hermann Memorial Restricted acccess networks, CVS marketplace plans and Medicaid plans. To verify that we are in-network with your specific Aetna plan, please login to your Aetna account and search for “Lactation Consultants” in the "Find A Doc" section of the website. Please be aware that you may need to expand the mileage to a 50-mile radius to find us.

To find out your specific benefits, please contact Aetna directly.

What is the difference between an in-network and out-of-network provider?

An in-network provider has a contract with your insurance company and agrees to provide services at a contracted rate, which is usually discounted.  An out of network provider does not have a contract with your insurance company and may charge any rate for their services.  Some plans cover out of network providers and other require you to see an in network provider.

Please read this document from Aetna explaining the difference between an in network and an out of network provider.

What if me and my baby have different insurance?

If either patient (lactating parent or baby) does not have coverage through Aetna or another insurance we are in network with, you will be charged a fee per non-covered patient for each standard visit

Due to insurance reimbursement rates, we bill your insurance for both the lactating parent and baby(ies) at each visit. For those patients who do not have in network insurance coverage for either the lactating parent or the baby you will be responsible for paying a non-covered patient fee.    A superbill can be provided for submission to the other insurance company for reimbursement purposes.

Will I have any out of pocket costs?

If your policy applies a co-pay, co-insurance or deductible, you will be responsible for paying for these charges.

Usually, services are covered at 100% under the mother, but sometimes there is a deductible, co-pay or co-insurance. These charges most commonly apply to baby; however, they may occur on mom in some plans.

Please contact Aetna to find out if your services will be subject to a deductible, copay or coinsurance. When speaking with them, you can reference the codes we use for our services.

  • Home visit codes: 99345/99350, s9443 and 99404
  • Office visit codes : 99205/99215, s9443 and 99404.

Understanding co-pays, co-insurance and deductibles

Are there situations where my insurance won't cover lacatation visits?

If our services are not covered by Aetna, you will be responsible for paying for them out of pocket, but we can offer a timely payment discount.

Some Aetna plans restrict coverage for lactation services. Examples of these plans include grandfathered plans and restricted access plans (such as Hermann Memorial). If you are in one of these plans, your lactation visit may not be covered by Aetna. 

Do I need to do anything for insurance coverage or get a referral prior to my visit?

 Some Aetna plans require a referral or precertification, and we recommend checking with Aetna to see if this applies to your plan.

Currently, we are aware that HMO plans, grandfathered plans (*such as Exxon, Huntsman International, Boon Chapman and Rice University*), selected Meritan plans and the Aexcel Plus Aetna Select plan require referrals.

If you are in one of these plans, you need to get a referral from your PCP and the baby’s PCP prior to your first visit or the services may not be covered.

If our claim is denied by Aetna because the services require a referral or pre-certification, and the referral or pre-certification was not obtained prior to your visit, you will be responsible for paying for these services out of pocket, but we can offer a timely payment discount.

Are there any other fees or charges I may have for the visit?

There are some fees that are not covered by Aetna, regardless of your plan.  If we know that a fee will not be covered, these fees will be billed to the patient.  Examples of non-covered services include the Home Visit Trip/Convenience Fee or a late cancellation or no-show fee.

If you have chosen to have a home visit, our standard trip fee/convenience surcharge will be charged to your credit card following your visit.  This fee is NOT billed or covered by insurance.

What about other insurance companies?

We are in network with several other insurance companies including:

  • Blue Cross Blue Shield
  • United HealthCare
  • Sana Health
  • We can not guarantee that your insurance provider will cover our services.
Why do I need to provide a credit card before my appointment? 

We require that all patients provide a credit card prior to the initial visit.  We will not schedule your appointment without having a credit card on file

  • You are authorizing us to save your card in your file and use it to pay the following fees:
  • Late cancellation or no-show fees 
  • Home Visit Trip / Convenience fee 
  • Co-Pay, co-insurance, deductibles or services that are not covered or denied. 
  • Non-covered services
  • Fees for non-covered patient

Policy Overview

We will submit a claim for your lactation services with Aetna, and we will attempt to pre-verify your benefits, but we do not guarantee coverage or benefits.

You are responsible for knowing and confirming your own lactation benefits, and confirming that we are an in network provider on your specific plan and if there are any restrictions or limitations on your benefits.

If your policy applies a co-pay, co-insurance or deductible, you will be responsible for paying for these charges.  We are legally obligated to bill you for these charges.

Some Aetna plans require a referral or precertification, and we recommend checking with Aetna to see if this applies to your plan.

If our claim is denied by Aetna because the services require a referral or precertification, and the referral or precertification was not obtained prior to your visit, you will be responsible for paying for these services out of pocket, but we can offer a timely payment discount.

If our services are not covered by Aetna, you will be responsible for paying for them out of pocket, but we can offer a timely payment discount.