Expecting parents often wonder about the scope of their health plan’s maternity benefits, especially concerning durable medical equipment like a breast pump. Health insurance plans are generally required to cover the cost of breastfeeding supplies, including a breast pump, often at no cost to the member. However, the specific terms of this coverage, such as the model and quantity allowed, are determined by the individual health plan. Understanding the difference between the federal mandate and your plan’s specific policy is the first step in determining if you can secure coverage for a second device.
The Legal Basis for Breast Pump Coverage
Most non-grandfathered private health plans must cover breastfeeding support and supplies without cost-sharing, removing financial barriers to preventative health services. This coverage typically includes the purchase or rental of a breast pump. While the law ensures access, it does not mandate a specific type, allowing insurers to differentiate between manual, standard electric, and hospital-grade models. Some plans may initially offer a manual pump, requiring documentation of medical need for an electric one.
The standard policy across insurance providers is to cover one breast pump per pregnancy. This limitation applies even if the member switches plans during the pregnancy or attempts to order through multiple suppliers. The coverage is tied to a specific pregnancy event and generally extends through the first year postpartum. If a second pump is to be covered, it requires specific, documented reasons.
Specific Scenarios for Obtaining a Second Pump
The most straightforward situation allowing for a second pump is a subsequent pregnancy, where the coverage benefit typically resets. When a new pregnancy is confirmed, the member is generally eligible for a new pump benefit, even if the previous one was received only a year or two earlier.
Beyond a new pregnancy, a second device is usually only covered under conditions of documented medical necessity. For instance, if a mother is carrying multiples, the physician can provide a prescription stating the need for a higher-grade or second device to establish and maintain a sufficient milk supply. Similarly, if an infant is born prematurely and requires an extended stay in the Neonatal Intensive Care Unit (NICU), a doctor may prescribe a hospital-grade rental pump in addition to the personal-use pump.
Specific maternal or infant health conditions can also justify dual coverage. If a mother experiences supply issues, or if the infant has a congenital condition that interferes with latching, the healthcare provider can document the need for a different type of device. This documentation may allow for coverage of a hospital-grade rental pump, which is considered distinct from a personal-use pump. In some cases, if the first pump received was a manual model, a subsequent medical need for a double-electric pump might be approved as a fulfillment of the original benefit.
Steps for Claiming Your Insurance Benefit
The process of obtaining your breast pump begins with verifying your specific benefits. You should contact your health insurance provider directly or check your member portal to confirm the exact coverage details, including covered pump models and any potential cost-sharing. This clarifies the plan’s rules regarding the timing of the order and the required documentation.
A prescription from a healthcare provider, such as an obstetrician, midwife, or pediatrician, is required because the breast pump is classified as Durable Medical Equipment (DME). The prescription should include a diagnosis code that justifies the need for the pump. In the case of a second pump, the prescription must specifically detail the medical necessity.
The next step involves working with a contracted DME supplier, as most insurance plans require the pump to be sourced through a specific in-network vendor. These suppliers handle the claim submission process and can help determine which pumps are covered under your plan’s contract. While the timing varies, most providers allow the pump to be ordered approximately 30 days before the estimated due date, though some plans may only approve the order after the baby is born.
Options When Dual Coverage is Not Available
If your circumstances do not meet the medical necessity criteria for a second pump, several alternative options exist for obtaining an additional device. Breast pumps and related supplies are considered qualified medical expenses, eligible for purchase using funds from a Flexible Spending Account (FSA) or a Health Savings Account (HSA). Using these pre-tax dollars can provide significant savings on the out-of-pocket cost.
Renting a hospital-grade pump, even without full insurance coverage, is a viable option for mothers needing a stronger device for a short duration. These pumps are designed for multiple users and offer the highest level of suction and cycle variability. Alternatively, many parents purchase a smaller, more portable pump out-of-pocket to use as a backup or a dedicated device for the workplace or travel, saving the insurance-covered pump for use at home.