Lactation Education and Support Services
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Lactation education and support services are considered medically necessary for those members who would like to breastfeed, but for whom the standard education and support services have not proven sufficient to secure sustained, effective breastfeeding.
Lactation education and support services may be provided by the following:
- A lactation educator-counselor
- An International Board-Certified Lactation Consultant (IBCLC)
Providers participating through participating physician groups (PPGs) must follow the PPGs’ processes.
Billing for Lactation Education and Support Services
Persons with lactation educator-counselor or IBCLC certifications are not recognized by the state of California as designated professionals who can be assigned a Medi-Cal provider number or bill Medi-Cal for services directly. A Medi-Cal provider, however, can bill for lactation support services under their Medi-Cal number if the services are rendered by a community perinatal health worker (CPHW), medical assistant (MA), registered nurse (RN), nurse practitioner (NP), or physician assistant (PA) who has one of these certifications. If the provider does not have a person on staff with a lactation certification, the provider may contract with a lactation consultant and reimburse that individual as a subcontracting employee.
Referral for Lactation Education and Support Services through CPSP Providers
Comprehensive Perinatal Services Program (CPSP)-certified providers can provide breastfeeding education, support and referrals in the antepartum and postpartum period to members. CPSP services can only be billed up to 60 days postpartum. After 60 days, CPSP providers can provide lactation support services but must bill using the appropriate ICD-10 or CPT codes.
Referral for Lactation Education and Support Services by Non-CPSP Providers
Health Net directly contracting (fee-for-service (FFS)) Medi-Cal participating providers who are not CPSP-certified can provide lactation services if a staff member is a lactation educator-counselor or IBCLC and bill using appropriate ICD-10 or CPT codes. Providers may refer a member to lactation services for infants up to age one.
Without a formal arrangement with a participating physician or facility, the lactation consultant is considered a non-participating provider and must contact Health Net prior to rendering service to confirm authorization and receive billing instructions.
Lactation durable medical equipment (DME) includes breast pumps, breast shells and nipple shields. These items help establish and sustain milk supply when nursing at the breast is difficult or not possible, and help eliminate breastfeeding difficulties.
A mother or baby may need lactation DME for one or more of the following reasons:
- Mother and infant are separated due to hospitalization
- Infant is unable to nurse (for example, latch or suck issues, post-operative, tube feedings)
- Mother has a physical condition requiring mechanical lactation assistance
- Mother is exclusively breastfeeding and is preparing to return to work or school
- Mother experiences nipple or breast pain
- Infant experiences latch-on difficulties
- Mother has flat or inverted nipples
- Mother has low milk supply
- Infant experiences slow weight gain
- Mother is breastfeeding a premature infant
- Mother is breastfeeding twins or triplets
- Mother is providing relactation or adoptive breastfeeding
- Infant has a neurological deficit or physical disability
Health Net Medi-Cal members may obtain the following types of breast pumps:
- Manual breast pump
- Personal-use electric breast pump and kit
- Hospital-grade electric breast pump and kit – rentals only (prior authorization required)
Prescriptions for lactation DME must be written by a licensed provider, including a physician, physician assistant, nurse practitioner, or certified nurse midwife.
Providers participating through participating physician groups (PPGs) must follow the PPGs’ processes.
Health Net has developed a Promoting and Supporting Breastfeeding in Your Practice toolkit for providers. The toolkit contains information about using the World of Health Organization growth charts, clinical protocols for breastfeeding and resources for provider offices, including online continuing medical education units and breastfeeding apps for smartphones. Also included in the toolkit is a checklist to ensure medical offices are breastfeeding-friendly and a poster that supports breastfeeding and can be placed anywhere in the office. Providers may request a toolkit by contacting Health Net Provider Services.