Does Insurance Cover an Elvie Breast Pump? The Straight Scoop and Everything Else You Need to Know

The burning question for many expectant and new mothers: Does insurance cover an Elvie breast pump? Generally, yes, most insurance plans in the US will cover a breast pump, thanks to the Affordable Care Act (ACA). However, the specifics, including which pump and how it’s covered, can vary wildly depending on your insurance plan. Let’s dive deep into the details and demystify the process.

Understanding Breast Pump Coverage Mandates

The Affordable Care Act’s Role

The Affordable Care Act (ACA) is the bedrock of breast pump coverage in the United States. It mandates that most health insurance plans cover preventive services without cost-sharing (like copays, deductibles, or coinsurance). Breastfeeding equipment, including breast pumps, falls under this umbrella.

What the ACA Doesn’t Guarantee

While the ACA mandates coverage, it doesn’t dictate which breast pump you receive. This is where the complexity arises. Each insurance company interprets and implements the ACA requirements differently. Some plans will only cover a basic manual or electric pump, while others may offer coverage for more advanced models like the Elvie.

Elvie: An Innovative, Desirable Option

Why the Elvie is So Popular

The Elvie breast pump stands out for its innovative design. It’s wirelessly rechargeable, wearable inside your bra, and operates with smart technology, allowing mothers to pump discreetly and conveniently. This makes it incredibly appealing for working mothers or those with busy lifestyles.

Premium Features, Premium Cost

The Elvie’s advanced features come at a higher price point compared to traditional breast pumps. This price difference is a major factor in whether insurance companies fully cover it or require an upgrade fee.

Deciphering Your Insurance Coverage for an Elvie

Contacting Your Insurance Provider: Step One

The absolute first step is to contact your insurance company directly. Ask these key questions:

• “Does my plan cover breast pumps?” (Even though the ACA mandates it, confirm!)
• “What types of breast pumps are covered?” (Specifically inquire about Elvie or “wearable” pumps.)
• “Do I need a prescription from my doctor?” (Almost always, yes.)
• “Do I need to use a specific supplier?” (Many plans require you to order through an approved vendor.)
• “Is there an upgrade fee if I choose a pump that costs more than the covered amount?” (This is crucial for Elvie.)
• “When can I order my breast pump?” (Coverage often begins a certain time before your due date.)

Understanding In-Network vs. Out-of-Network Suppliers

Your insurance plan will likely have a list of in-network suppliers. These are companies that have negotiated rates with your insurance provider. Using an in-network supplier usually means lower out-of-pocket costs. Ordering from an out-of-network supplier could mean you pay the full retail price and then have to submit a claim for reimbursement, which may or may not be fully covered.

The Prescription Requirement

Almost all insurance plans require a prescription from your doctor or healthcare provider for a breast pump to be covered. This prescription must specify “breast pump” and may need to include your diagnosis code related to pregnancy or postpartum care.

Upgrade Fees: The Reality of Advanced Pumps

If your insurance covers a breast pump, but not the full cost of the Elvie, you may be responsible for an upgrade fee. This is the difference between the amount your insurance covers and the retail price of the Elvie. Upgrade fees can range from a few dollars to several hundred dollars, so understanding this upfront is vital.

Navigating the Ordering Process

Utilizing Durable Medical Equipment (DME) Suppliers

Breast pumps are typically classified as Durable Medical Equipment (DME). This means you’ll likely order your pump through a DME supplier that specializes in medical equipment. Your insurance company or doctor can provide you with a list of approved DME suppliers.

Paperwork and Verification

Be prepared for paperwork! You’ll likely need to provide your insurance information, doctor’s prescription, and potentially fill out additional forms. The supplier will typically verify your insurance coverage and handle the claim submission process.

Waiting for Your Pump

Once your order is placed and your insurance is verified, the supplier will ship your breast pump. Delivery times can vary, so plan accordingly.

Frequently Asked Questions (FAQs)

1. What happens if my insurance denies coverage for an Elvie?

If your insurance initially denies coverage, don’t give up! File an appeal. Provide a letter from your doctor explaining the medical necessity of a wearable, hands-free pump like the Elvie, especially if you have a demanding job, mobility issues, or other circumstances that make traditional pumping difficult.

2. Can I get a breast pump before the baby is born?

The answer to when you can get a breast pump varies by insurance. Some plans allow you to order it a month or two before your due date, while others require you to wait until after the baby is born. Check your plan’s specific guidelines.

3. Are manual breast pumps also covered?

Yes, manual breast pumps are also covered under the ACA mandate. However, many women opt for electric pumps for their convenience.

4. What if I have Medicaid?

Medicaid also typically covers breast pumps, often with similar requirements as private insurance. However, coverage details can vary by state, so check your state’s specific Medicaid guidelines.

5. Is a double electric breast pump always covered?

While the ACA mandates breast pump coverage, it doesn’t guarantee a double electric pump specifically. Many plans do cover them, but some only cover a single electric pump or a manual pump.

6. Can I get reimbursed if I buy a breast pump myself and then submit a claim?

It depends on your insurance plan. Some plans allow for reimbursement, but others require you to order through an approved supplier. Always check with your insurance company before purchasing a pump out-of-pocket if you intend to seek reimbursement.

7. What if I have TRICARE (military insurance)?

TRICARE does cover breast pumps, including electric pumps. You’ll need a prescription from a TRICARE-authorized provider and will likely need to order through a specific supplier.

8. Does my insurance cover replacement parts for my Elvie?

Coverage for replacement parts varies widely. Some insurance plans may cover replacement parts for a limited time, while others do not. Inquire with your insurance provider about their policy on replacement parts.

9. Can I use a Flexible Spending Account (FSA) or Health Savings Account (HSA) to pay for an Elvie?

Yes! You can typically use your FSA or HSA funds to pay for a breast pump, including the Elvie, and any associated upgrade fees or replacement parts.

10. What if I have two insurance plans?

If you have dual insurance coverage, the primary insurance will typically be responsible for covering the breast pump. Coordinate with both insurance companies to determine which plan is primary and how to file the claim.

11. Is there a limit to how many breast pumps I can get covered during my pregnancy or breastfeeding journey?

Generally, insurance plans cover one breast pump per pregnancy. While replacement parts are sometimes covered, obtaining a second complete pump under the same pregnancy can be challenging unless there’s a documented medical necessity.

12. Where can I find more information about my rights regarding breast pump coverage?

The Department of Labor website and the HealthCare.gov website offer comprehensive information about the Affordable Care Act and your rights regarding preventive services, including breast pump coverage. You can also contact your state’s insurance department for further assistance.

The Bottom Line

While navigating insurance coverage for an Elvie breast pump can feel overwhelming, understanding your rights and taking the necessary steps – contacting your insurance provider, obtaining a prescription, and utilizing an in-network supplier – will significantly increase your chances of securing coverage, whether full or partial. Remember, knowledge is power, and advocating for your needs as a new mother is crucial.