CMS Logo DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Center for Medicaid and CHIP Services --- Medicaid Coverage of Lactation Services Issue This issue brief sets forth current levels of State Medicaid coverage for lactation services and explores how CMS can encourage and assist States in increasing access to such services. Background Improving the health of the population and reducing preventable causes of poor health, such as obesity, is a priority of the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS).i Current research shows that the practice of breastfeeding for the first 6 to 12 months of life is highly beneficial for both the mother and infant. On January 20, 2011, the United States Surgeon General released “The Surgeon General’s Call to Action to Support Breastfeeding.” ii This report indicates that there is a 32% higher risk of childhood obesity and a 64% higher risk of type 2 diabetes for children who are not breastfed. An extensive body of research supports these assertions and provides evidence of the positive effects of breastfeeding on both short and long term infant and maternal health. iii Professional organizations advocate for exclusive breastfeeding during the first 6 months of life, meaning that infants should not be given any other substance other than breast milk, including water.iv Breastfeeding also serves additional advantages for low birth weight infants. Human milk consumption is associated with a reduction in sepsis infections and gastrointestinal illnesses among very low birth weight newborns in the neonatal intensive care unit (NICU).v The U.S. Preventive Services Task Force (USPSTF) specifically recommends coordinated interventions throughout pregnancy, birth, and infancy to increase breastfeeding initiation, duration, and exclusivity.vi Such recommended interventions include formal breastfeeding education for mothers and families, direct support of the mother during breastfeeding observations, and the training of health professional staff about breastfeeding and techniques for breastfeeding support.vii The opportunity to promote and provide support for breastfeeding occurs many times throughout the interactions that women have with various types of health care providers during and after pregnancy. Categories of Coverage for Lactation Services All States participating in the Medicaid program cover pregnancy-related services. 42 C.F.R. § 440.210 defines “pregnancy-related services” as those that are necessary for the health of the pregnant woman and fetus, or that have become necessary as a result of the woman having been pregnant. These include, but are not limited to, prenatal care, delivery, postpartum care, and family planning services. States must provide coverage of pregnancy-related services for an extended postpartum period, defined as beginning on the last day of pregnancy and extending through the end of the month in which the 60-day period following termination of pregnancy ends. This definition of “pregnancy-related services” is broad enough to encompass lactation services. Due to the multiple health benefits associated with breastfeeding, CMS encourages States to go beyond the requirement of solely coordinating and referring enrollees to the Special Supplemental Food Program for Women, Infants, and Children (WIC) (established in 42 C.F.R. § 431.635) and include lactation services as separately reimbursed pregnancy-related services. States may use the following Medicaid coverage categories to reimburse lactation services: . Inpatient hospital services (other than services in an institution for mental disease), per Social Security Act (SSA)§ 1905(a)(1); . Outpatient hospital services, per SSA § 1905(a)(2)(A) and 42 C.F.R. § 440.10; . Early and periodic screening, diagnostic, and treatment services for individuals who are eligible under the plan and are under the age of 21, per SSA § 1905(a)(4)(B); . Physicians’ services furnished by a physician under the physician’s supervision, whether furnished in the office, the patient’s home, a hospital, or a nursing facility, or elsewhere, per SSA § 1905(a)(5)(A); . Services furnished by a nurse-midwife, which the nurse-midwife is legally authorized to perform under State law, per SSA § 1905(a)(17); . Freestanding birth center services, per SSA § 1905(a)(28); and . Services furnished by nurse practitioners per 42 C.F.R. § 440.166 and other licensed practitioners per 42 C.F.R. § 440.60. Current State Practices Because lactation services are not specifically mentioned in the Medicaid statute or Federal Medicaid regulations, not all States separately reimburse lactation services as pregnancy-related services.viii In fact, States vary widely in the amount and scope of coverage they provide for lactation services as a part of prenatal, postpartum, and infant care. The Kaiser Family Foundation and the George Washington University Department of Health Policy conducted a survey in 2008 to assess each State’s Medicaid coverage of perinatal services.ix This survey, to which 44 States provided a response, focused on three main categories of lactation services: 1) Breastfeeding Education, 2) Individual Lactation Consultation, and 3) Equipment Rentals (see attachment). The findings of the study showed that despite the establishment of breastfeeding as an important preventive health measure, Medicaid coverage of lactation services was far from comprehensive. While States do cover lactation related services as a part of the hospital/facility fee after delivery, not all States cover and separately reimburse for such services. Specifically, 25 of the responding States covered breastfeeding education services, 15 of the responding States covered individual lactation consultations, and 31 of the responding States covered equipment rentals. Some States have taken additional or alternative steps to promote breastfeeding. For example, some provide Medicaid coverage for donor milk from a human milk bank for infants whose mothers are unable to breastfeed due to medical reasons or in cases where the infant cannot tolerate formula use.x New Hampshire Medicaid provides coverage of a Maternal Postpartum Assessment, which specifically includes an evaluation of whether the mother is properly breastfeeding and provides the accompanying postpartum education to ensure she continues to breastfeed.xi Florida operates a Medicaid waiver program that coordinates prenatal care through monthly outreach and case management. The program specifically stresses healthy nutrition and breastfeeding habits, but is limited to Medicaid enrollees identified as high-risk for poor birth outcomes or those referred to the program by their health care provider.xii Aside from variation in the amount and scope of coverage provided for lactation services, States also differ in the ways that these services are billed and coded. For example, in Illinois, both breastfeeding education and individual lactation consultations are billed as part of an exam, not as a separate service.xiii Some States simply allow providers to bill individual lactation consultations as part of an “Evaluation and Management” visit. In many cases, lactation consultations may be provided as part of Childbirth Education Classes or covered (and coded) as part of a woman’s inpatient hospital stay.xiv The home health nurse visit provided after discharge from the hospital also allows health care providers to engage in a one-on-one lactation evaluation and consultation for new mothers. The following provides examples of different codes that States use for billing and receiving federal matching funds for coverage of lactation services: . Lactation Consultation (face-to-face visit), HCPCS code S9443 . Postpartum Care and Examination of Lactating Mother, ICD-9 code V24.1 . Manual Breast Pump purchase, CPT Code E0602 . Hospital Grade Electric Breast Pump rental, CPT Code E0604 . Individual Electric Breast Pump purchase, CPT Code E0603 Example of a State Benefit Package Rhode Island provides the following benefit package for breastfeeding mothers enrolled in Medicaid. None of the services are associated with co-payments.xv Benefit Criteria Education Prenatal Breastfeeding Classes/ Childbirth Education Classes Covered benefit – group and individual sessions No referral or authorization needed Breastfeeding Support Group Not a covered benefit Lactation Support In-patient hospital Covered as part of inpatient stay Outpatient hospital Covered benefit – initial consult must occur within first two weeks of delivery. Benefit limited to 2 additional visits within first month after delivery Home Covered benefit – prior approval required. Initial consult must occur within first two weeks of delivery. Benefit limited to 2 additional visits within first month after delivery Equipment Manual Breast Pump Purchase Covered benefit for medical necessity or for mother returning to work or school (up to child’s first birthday) Requires prescription Hospital Grade Electric Breast Pump Rental Covered benefit for medical necessity or for mother returning to work or school (up to child’s first birthday) Requires prescription Individual Electric Breast Pump Purchase Covered benefit for medical necessity or for mother returning to work or school (up to child’s first birthday) Requires prescription Pump Kits Purchase Covered benefit – authorized with electric pump (1 maximum) Options for Improving Access to Lactation Services Aside from providing a benefit package, there are a number of strategies that States can undertake to improve access to lactation services for Medicaid beneficiaries. . Encourage managed care entities/organizations and other providers to direct patients to Baby-Friendly Hospitals. The Baby-Friendly Hospital Initiative was established by the World Health Organization (WHO) and UNICEF in 1991 and gives special recognition to hospitals and birthing centers that follow the Ten Steps to Successful Breastfeeding for Hospitals.xvi As of November 17, 2011, there are 121 Baby-Friendly Hospitals and Birth Centers throughout the United States that provide new mothers with the information and skills needed to successfully initiate and continue breastfeeding.xvii Baby-Friendly Hospitals have experienced significant increases in the rates of successful and sustained breastfeeding among Medicaid and privately insured mothers, more so than in non-Baby-Friendly Hospitals.xviii . Because primary care interventions to promote and support breastfeeding received a grade of B from the USPSTF, coverage of lactation services without cost-sharing will be eligible for a 1 percentage point increase in federal medical assistance percentage (FMAP) in 2013 per Section 4106 of the Affordable Care Act. CMS encourages States to begin formulating coverage policies for such services. i Other agencies within HHS have undertaken the following initiatives related to breastfeeding: 1) The Centers for Disease Control and Prevention (CDC) publishes a CDC Guide to Breastfeeding Interventions (Shealy KR, Li R, Benton-Davis S, Grummer- Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005) ; 2) The Health Resources and Services Administration (HRSA) operates the Business Case for Breastfeeding program, which is a comprehensive program designed to educate employers about the value of supporting breastfeeding employees in the workplace; 3) The Agency for Healthcare Research and Quality (AHRQ) provides information and research that assesses breastfeeding with maternal and infant health outcomes; 4) The Office on Women’s Health published the 2000 HHS Blueprint for Action on Breastfeeding. ii US Department of Health and Human Services, The Surgeon General’s Call to Action to Support Breastfeeding, 2011, available at: http://www.surgeongeneral.gov/topics/breastfeeding/calltoactiontosupportbreastfeeding.pdf. iii Ip S, et al. Breastfeeding and Maternal and Infant Outcomes in Developed Countries: Evidence Report/Technology Assessment Number 153, Agency for Health Care Research and Quality Publication No. 07-E007; April 2007, available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf. iv The American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Nurse Midwives, American Dietetic Association, and American Public Health Association all recommend that infants be breastfed for a minimum of 12 months. v El-Mohandes A, Picard MB, Simmens SJ, et al. Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis Journal of Perinatology 1997; 2:130-134; Taylor G, Minich N, Hack, M. The Effect of Maternal Milk on Neonatal Morbidity of Very Low-Birth-Weight Infants. Arch Pediatric and Adolescent Medicine. 2003;157:66-71; Meinzen-Derr J, Poindexter B, Wrage, L, Morrow A, Stoll B, DonovanE. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death, Journal of Perinatology. 2009 Jan; 29(1):57-62. vi USPSTF, Primary Care Interventions to Promote Breastfeeding: Recommendation Statement, October 2008, available at: http://www.uspreventiveservicestaskforce.org/uspstf08/breastfeeding/brfeedrs.htm. vii Ibid. viii See 42 C.F.R. 440.210 Required Services for the Categorically Needy and 42 C.F.R. 440.220 Required Services for the Medically Needy. . Encourage managed care organizations to either collect data that establishes a baseline for breastfeeding rates and/or initiate a performance improvement project (PIP) or focused study that seeks to increase rates of breastfeeding within the population. For example, a health plan in New York State operates a performance improvement project that seeks to increase education among pregnant women, mothers, and providers while specifically stressing breastfeeding in the first years of life and provider encouragement of breastfeeding.xix . Eliminate variation of coverage among Medicaid managed care plans and encourage managed care contractors to provide breastfeeding education, either by means of referrals to Special Supplemental Food Program for Women, Infants, and Children (WIC) or direct provision of the services through its provider network.xx WIC provides breastfeeding women with lactation support by means of counseling, the provision of breastfeeding educational materials, the option to receive an enhanced food package, follow-up support through peer counselors, and the provision of breast pumps or other equipment to help reinforce a healthy and successful breastfeeding routine. xxi .xxii . Coordinate with the “Let’s Move!” initiative, launched by the First Lady of the United States, Michelle Obama, in an effort to promote breastfeeding as one of the many strategies to prevent childhood obesity.xxiii . Disseminate information to providers that discuss the benefits of lactation services, as well as information and other resources regarding the promotion of lactation services. January 10, 2012 ix Stewart A, Cox M, Doamekpor L, Ranji U, Salgancioff A, State Medicaid Coverage of Perinatal Services: Summary of State Survey Findings. The Henry J. Kaiser Family Foundation, November 2009, available at: http://www.kff.org/womenshealth/upload/8014.pdf. x Texas Medicaid and Health Partnership, Texas Health Steps Medicaid Manual: Donor Human Milk, available at: http://www.tmhp.com/HTMLmanuals/TMPPM/2008/2008%20TMPPM-46-108.html. xi N.H. ADMIN. RULES [HE-W] 547.04 (2011). xii AHCA, Florida Medicaid Summary of Services for Fiscal Year 2010-2011 at 105, available at http://ahca.myflorida.com/Medicaid/pdffiles/SS_10_100501_SOS_ver2-4_1164_1011_FINAL2.pdf. . xiii Stewart A, Cox M, Doamekpor L, Ranji U, Salgancioff A, State Medicaid Coverage of Perinatal Services: Summary of State Survey Findings. The Henry J. Kaiser Family Foundation, November 2009, available at: http://www.kff.org/womenshealth/upload/8014.pdf. xiv Rhode Island Department of Health, Breastfeeding Insurance Benefits Guidelines, available at: www.health.ri.gov/family/breastfeeding/insurancebenefits.php. xv Ibid. xvi The Ten Steps to Successful Breastfeeding are: 1) Have a written breastfeeding policy that is routinely communicated to all health care staff; 2) Train all health care staff in skills necessary to implement this policy; 3) Inform all pregnant women about the benefits and management of breastfeeding; 4) Help mothers initiate breastfeeding within one hour of birth; 5) Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants; 6) Give newborn infants no food or drink other than breast milk, unless medically indicated; 7) Practice “rooming in” which is allowing the mother and infant to remain together 24 hours a day; 8) Encourage breastfeeding on demand; 9) Give no pacifiers or artificial nipples to breastfeeding infants; and 10) Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. For more information, please see http://www.babyfriendlyusa.org/eng/index.html. xvii To be recognized as a Baby-Friendly Hospital, facilities must register with Baby-Friendly USA and undergo an on-site assessment to demonstrate the facility has integrated the “Ten Steps to Successful Breastfeeding” into hospital policies and procedures for healthy newborns. More detailed information can be found in the Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation, 2010 edition, available at: http://babyfriendlyusa.org/eng/docs/2010_Guidelines_Criteria_4.19.11.pdf. xviii Philipp B, Merewood A, Miller L, et al., Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting. Pediatrics. 2001; 108(3): 677-681. xix New York State Medicaid Managed Care Performance Improvement Projects, 2009-2010 Pediatric Obesity - Summary of Projects, available at: http://www.health.ny.gov/health_care/managed_care/reports/pediatric_obesity.htm. xx Specifically, 42 C.F.R. 431.635 requires the coordination of Medicaid with WIC, which includes providing written notice of the availability of WIC benefits to all individuals in the State who are determined eligible for Medicaid and who are pregnant, postpartum, breastfeeding, or a child under the age of five. In addition, the State must at least annually provide written notice of the availability of WIC benefits (including the telephone number and address of the local WIC agency) to all Medicaid recipients who might be pregnant, postpartum, or breastfeeding. xxi United States Department of Agriculture, Food & Nutrition Service, Women, Infants, and Children, available at: http://www.fns.usda.gov/wic/. xxii All states that utilize managed care to deliver Medicaid services are required by 42 C.F.R. 438.358 to engage in three mandatory external quality review activities, including the validation of PIPs and performance measures. xxiii For more information, please see www.letsmove.gov.