Understanding Your Aetna Coverage

We understand that insurance can be confusing—we created this article to explain as best we can.

Understanding Aetna’s “six covered visits”

If your plan covers “six visits” at 100%, this refers to six billing codes, not six appointments. You and your baby each get six codes. Per standard medical billing practice, multiple billing codes are used at each appointment—typically, 1-2 codes for the parent and 1 code for the baby per session (for insurance purposes, you and your baby are considered separate people/patients and must be billed separately). You and your baby each get six codes.

What happens after the “six visits” are up?

The good news is, it’s “six visits” that are fully covered. Most plans will still offer partial coverage for a majority of each session after the “six visits” are up—just expect to pay a portion out of pocket (see our chart at the bottom of the page for estimates). The partial coverage still offers significant savings, as you’d pay $250-350 per session without insurance.

Key Points to Ask Aetna

We recommend calling Aetna prior to your first appointment, to gain clarity about your plan’s coverage and benefits.

1. Get the call reference details:
   • Ask for the representative’s name and call reference number. Write down these details, along with the date and time of your call. These details can be helpful to refer back to if later there are any disputes.
2. Provider Network:
   • Verify that we are in-network with your plan. Use our NPI number: 1144920596.
3. Coverage Verification:
   • Confirm whether your plan offers lactation benefits and whether there is any associated cost-sharing (copays, co-insurance, or deductible) for both you and your baby. For insurance purposes, you and your baby are considered two separate people/patients. Each patient present at the visit has to be billed separately.
     
4. When the baby has double coverage or doesn’t have any Aetna coverage:
   • If your baby has coverage under both your insurance plan and your partner's plan at the same time, the NAIC's "Birthday Rule" kicks in. If your partner’s birthday falls earlier in the year than yours, your partner’s plan would be considered your baby's primary plan. If that plan is not an Aetna plan, you’ll need to pay a deposit for the baby’s portion of the charges ($75 per visit). We’ll refund it once we receive payment from Aetna. See our Payment Policies for details.
     • The process of getting two insurance companies to agree on “who pays what” can take months—your deposit helps us pay our staff on time while the insurance companies duke it out.
     • Note: Some plans have “dependent coverage" which automatically includes the baby under the non-birth parent’s insurance plan for the first 30 days of life, even if you don’t request it. This has caused issues in the past, so we recommend confirming with your partner’s plan.
   • If Aetna is not your baby’s primary insurance, we cannot bill Aetna for the baby’s portion of the charges until we receive a copy of the denied claim from their primary insurance.
   • If your baby doesn’t have Aetna coverage at all, you’ll need to pay $75 per session(non-refundable)to cover the baby’s portion of the charges. This is only billed for sessions where we perform any assessments or make any care recommendations for baby.
     
5. Deductible Status:
   • Check whether your deductible has been met and if not, how much is left. Expect to pay co-insurance for baby’s portion of the visit (usually, $5-20 per visit) until your deductible has been met.
     
6. Visit Limits:
   • Inquire about the number of covered visits, and whether any of your benefits have already been used in the current year. Some “free” online lactation classes (especially those offered by companies who sell pumps through insurance) use up your benefits.

Navigating insurance can be tricky. Asking these questions and reading our Payment Policies will help you understand your coverage and potential costs. Feel free to reach out if you have further questions after speaking with Aetna!

We have included a chart below with estimated out of pocket costs per visit. Aetna would ultimately determine the amounts owed, we are simply sharing these estimates as a courtesy based on what previous patients have encountered. Most clients see us for 4-6 sessions, on average.