Applying for a Gap Exception
Step 1- Check whether your plan covers lactation care
Simply call the number on the back of your card and ask if your specific plan covers lactation care. If yes, proceed to Step 2! If not, you can ask why your plan is not subject to the Affordable Care Act (some plans are exempt, but it's rare.)
Step 2- Ask for in-network providers in your area
Tell the representative that you'd like help finding an in-network IBCLC who can see you in-person for care in your area. Maybe they'll have one! They usually give people a list of providers who do not, in fact, offer lactation support. Usually these are OBs, midwives, or nurse practitioners who do not have IBCLC credentials and do not see people for outpatient lactation support.
They may also direct you to a virtual only company and tell you that your insurance will cover you for telehealth through these services. If that feels appropriate, you can totally take advantage of it. Virtual is awesome for some things, I use it a lot! But, it is not appropriate for issues like concerns about infant weight gain, pump testing, functional oral assessments for babies, etc.
Step 3- Request a gap exception (sometimes called a network deficiency request)
If you feel that in-person care is most appropriate for your needs and they cannot provide you with an in-network provider within reasonable driving distance, then you have standing to ask for a "gap exception" or “network deficiency.” This is a fancy way of saying that you pay a lot of moo-lah for your insurance plan, they are supposed to cover you for lactation. If they can't, they should agree to cover you seeing an out-of-network provider (that's me.) If they agree, then you would pay the private-pay rate up front to schedule your visit, then send them the detailed superbill I provide for you, and they should reimburse you.
If they agree, ask them to date the network deficiency starting the day you speak with them for as long as they will agree (12 months is appropriate considering the World Health Organization recommends breastfeeding for 2 years, as long as mutually desired.)
They will ask you for specific information about your IBCLC (that's me) and their practice location. You may have already received this in an email. If not, just let me know: [email protected].
How payment works with a gap exception
Families pay using the private-pay option on our website each time they schedule a visit. After each visit, you will receive a superbill (a fancy-pants, detailed receipt) to submit to your insurance company and they *should* then reimburse you directly. I wish I could guarantee that they will reimburse you in full in a timely manner, but I cannot. Sadly, reimbursement is sometimes only partial and sometimes does not happen at all. I am always hopeful, but I want families to go in with eyes open!
Some general info on what a gap exception is…
https://www.verywellhealth.com/network-gap-exception-what-it-is-how-it-works-1738418
If you feel your insurance company is not conducting business in accordance with the law, you can request a review…https://oci.georgia.gov/insurance-resources/health
https://externalappeal.cms.gov/ferpportal/#/home
Simply call the number on the back of your card and ask if your specific plan covers lactation care. If yes, proceed to Step 2! If not, you can ask why your plan is not subject to the Affordable Care Act (some plans are exempt, but it's rare.)
Step 2- Ask for in-network providers in your area
Tell the representative that you'd like help finding an in-network IBCLC who can see you in-person for care in your area. Maybe they'll have one! They usually give people a list of providers who do not, in fact, offer lactation support. Usually these are OBs, midwives, or nurse practitioners who do not have IBCLC credentials and do not see people for outpatient lactation support.
They may also direct you to a virtual only company and tell you that your insurance will cover you for telehealth through these services. If that feels appropriate, you can totally take advantage of it. Virtual is awesome for some things, I use it a lot! But, it is not appropriate for issues like concerns about infant weight gain, pump testing, functional oral assessments for babies, etc.
Step 3- Request a gap exception (sometimes called a network deficiency request)
If you feel that in-person care is most appropriate for your needs and they cannot provide you with an in-network provider within reasonable driving distance, then you have standing to ask for a "gap exception" or “network deficiency.” This is a fancy way of saying that you pay a lot of moo-lah for your insurance plan, they are supposed to cover you for lactation. If they can't, they should agree to cover you seeing an out-of-network provider (that's me.) If they agree, then you would pay the private-pay rate up front to schedule your visit, then send them the detailed superbill I provide for you, and they should reimburse you.
If they agree, ask them to date the network deficiency starting the day you speak with them for as long as they will agree (12 months is appropriate considering the World Health Organization recommends breastfeeding for 2 years, as long as mutually desired.)
They will ask you for specific information about your IBCLC (that's me) and their practice location. You may have already received this in an email. If not, just let me know: [email protected].
How payment works with a gap exception
Families pay using the private-pay option on our website each time they schedule a visit. After each visit, you will receive a superbill (a fancy-pants, detailed receipt) to submit to your insurance company and they *should* then reimburse you directly. I wish I could guarantee that they will reimburse you in full in a timely manner, but I cannot. Sadly, reimbursement is sometimes only partial and sometimes does not happen at all. I am always hopeful, but I want families to go in with eyes open!
Some general info on what a gap exception is…
https://www.verywellhealth.com/network-gap-exception-what-it-is-how-it-works-1738418
If you feel your insurance company is not conducting business in accordance with the law, you can request a review…https://oci.georgia.gov/insurance-resources/health
https://externalappeal.cms.gov/ferpportal/#/home
