Policies for clients with Aetna Insurance

Bayou City Breastfeeding is in network with most aetna policies, except for Memorial Hermann ACO plans, CVS marketplace plans, and Medicaid plans. To verify that we are in network with your specific plan, please log in to your aetna account (https://www.aetna.com/AccountManagerV3/v/login) and search for "Lactation Consultants" in the "Find a Doc" section of the website. Please be aware you may need to expand the mileage to see us. 

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

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.

If we can't bill an insurer for either the parent or baby, you’ll need to pay a non-covered patient fee: $80 for the parent and $60 for the baby.  

If we can bill insurance for both patients,  you might also pay extra if the plan:

• 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.

Aetna incorrectly tells their patients that they will have "6 free lactation visits a year". What they are referring to is the CPT code that tells them your visit is for lactation. Due to the nature of our dedicated care and length of our visits, we cannot bill this code alone. We pair it with another time based CPT code to cover our time spent. This code can have copay/ coinsurance/ deductible applied. Aetna also counts bundled codes as multiple visits so your lactation benefits will max out between visits 2-3. When lactation benefits exhaust there will be out of pocket costs associated. Using the below CPT coding info, you can reach out to Aetna to check the amounts of these costs. 

• Home Visit Codes: 
  • Mom: 99345 + S9443. Diagnosis Z39.1
  • Infant: 99404 + S9443. Diagnosis Z76.89
• Office Visit Codes: 
  • Mom: 99205/ 99404 + S9443. Diagnosis Z39.1
  • Infant: 99404 + S9443. Diagnosis Z76.89
• Telehealth Visit Codes:
  • Mom: 99204 + S9443. Diagnosis Z39.1
  • Infant: 99204 + S9443. Diagnosis Z76.89

Please read this to help understand copay / coinsurance / deductible. https://www.aetna.com/health-guide/explaining-premiums-deductibles-coinsurance-and-copays.html.html

For Aetna members, as of March 2024, we are now seeing Aetna apply the entire BILLED amount to patient responsibility for home visits, stating that lactation is not a reason for an in home visit. Therefore, if you use your Aetna insurance benefits, Aetna may apply the full billed amount to patient responsibility, plus you will have a $70 travel fee. An office and virtual visit are more cost-effective choices with minimal to no out of pocket costs.

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

Some Aetna plans restrict coverage for lactation services. Examples of these plans include: 

• Grandfathered plans (Exxon, etc..)
• Restricted Access Plans (Memorial Hermann)

If you are in one of these plans, your lactation visits may not be covered by Aetna. 

 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.

Due to the overwhelming claims issues, we no longer accept the Memorial Hermann plan to bill directly. However, we do offer timely payment discounts and can provide a superbill for you to submit on your own. You can also go through the process of getting GAP Coverage (Network Deficiency Coverage) on your own which may help you with reimbursement. 

There are some fees that are not covered by insurance, regardless of your plan. If we know that a fee will not be covered, this fee will be billed to the patient. Examples of non- covered services include but are not limited to: 
        * Home Visit Travel Fee ($70)
        * Late Cancellation/ No Show Fee

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