Appellate Court Affirms Denial of Coverage for Out-of-Network Lactation Services

This appeal was brought by health plan participants who were denied coverage for lactation support and counseling services provided by out-of-network providers. The trial court previously overturned the plan’s denial of coverage for participants who lacked adequate access to in-network services, but upheld the plan’s adverse determination for participants who sought out-of-network care even though they could have gone to in-network providers (see our Checkpoint article). The appellate court affirmed the denial of coverage for the participants who chose out-of-network care despite having access to nearby in-network lactation specialists. The court explained that while the Affordable Care Act (ACA) requires plans and insurers to fully cover lactation services in accordance with comprehensive guidelines, regulations clarify that plans that offer participants access to in-network lactation services are not required to cover services provided by an out-of-network provider.

EBIA Comment: Group health plans and insurers that are subject to the ACA’s preventive health services mandate must provide coverage for certain preventive services without imposing copayments, coinsurance, deductibles, or other cost-sharing requirements. However, as illustrated by this case, plans may limit or exclude out-of-network coverage in some circumstances. Specific guidelines about the preventive services that must be covered are available on the HealthCare.gov website, which is updated on an ongoing basis. The guidelines specify that prenatal and postnatal lactation support, counseling, and equipment rental must be covered without cost-sharing. Counseling services may be provided by any providers acting within the scope of their state licenses or certifications (e.g., registered nurses), and coverage without cost-sharing cannot be limited to inpatient services. For more information, see EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”), EBIA’s Group Health Plan Mandates manual at Section XIV.C (“Required Preventive Health Services Coverage”), and EBIA’s Self-Insured Health Plans manual at Section XIII.C.1 (“Federally Mandated Benefits: Preventive Health Services”).

Contributing Editors: EBIA Staff.