Breast-feeding Supplies/Breast Pumps

If the health reform law requires health plans to cover renting breast pumps at no cost-share why is UnitedHealthcare also covering the purchase of breast pumps without cost-share?

In addition to covering the rental of hospital-grade breast pumps, UnitedHealthcare also covers the purchase of a portable double-electric breast pump without cost-share. Only hospital-grade breast pumps are intended to be rented since they are designed for multiple users. We believe many members will prefer to purchase a more portable and convenient electric breast pump rather than rent hospital-grade equipment.

How does a member receive a breast pump without cost-share?

A member must contact a network doctor or one of our national durable medical equipment (DME) suppliers. The supplier will ship the breast pump directly to the member. The doctor or DME supplier will bill UnitedHealthcare directly for reimbursement. Members may call the number of the back of their ID card for DME supplier information.

Is there a time limit that a woman must purchase or rent breast-feeding equipment following the birth of her baby to qualify without cost-share?

Effective April 1, 2013, personal use double-electrical pumps are covered for women who are lactating and request a breast pump within one year (365 days) following delivery. Hospital-grade breast pumps and the personal use attachment kit are covered for members who meet the following criteria:

1. The woman is a lactating mother
2. The breast pump is obtained within the first two months (60 days) following delivery
3. The baby has one or more of the following criteria:

• Hospitalized newborn
• Congenital malformations or genetic abnormalities that impact feeding (e.g. cleft lip and palate, Down Syndrome)

After 10 months of renting, hospital-grade pumps automatically convert to a purchase.

Remember these changes are part of the expanded list of women's preventive care services that go into effect for non-grandfathered plans on the health plan's first renewal date on or after Aug. 1, 2012.

May members purchase a breast pump at a retail store and turn in the receipt for reimbursement?

No. Members may only obtain a breast pump through a network doctor or DME supplier.

Is prior authorization required for a breast pump?

Currently, prior authorization is not needed for breast pumps. Providers will need to bill for breast pumps consistent with our Preventive Care Services Coverage Determination Guideline (PDF), or they can direct women to one of the national DME suppliers to get their breast pump. Providers will verify that a woman is eligible to receive a breast pump as a preventive service.

Colonoscopy

How does UnitedHealthcare cover colon cancer screenings?

Under the health reform law, preventive colorectal cancer screenings are covered without cost-share. UnitedHealthcare covers colonoscopy, sigmoidoscopy and fecal occult blood testing without cost-sharing for all members at an age-appropriate age and/or risk status. UnitedHealthcare also covers CT colonography as a preventive screening test for colorectal cancer for commercial members. All services for a preventive colonoscopy (e.g. associated facility, anesthesia, pathologist, and doctor fees) are processed under the preventive care services benefit and covered without cost-share.

Contraception Coverage

What if a doctor doesn't maintain an inventory of IUDs in his or her office and asks the member to purchase an IUD at a pharmacy?

IUDs can be expensive for doctors to purchase and stock in their offices. Doctors who do not stock IUDs can obtain the Mirena® brand levonorgestrel-releasing intrauterine system "on demand" from CVS Caremark Specialty Pharmacy. Contact CVS Caremark at 1-800-237-2767 or Fax 1-800-323-2445.

Please note that we cannot reimburse members who purchase IUDs at a pharmacy, even if that pharmacy is a network pharmacy because IUDs are covered under the medical benefit, not the pharmacy benefit.

When are contraceptives available without cost-sharing?

For renewing fully insured plans that cover preventive services at 100%, the effective dates for medical coverage and pharmacy coverage may be different. Medical coverage for women's preventive care services begins on the plan's first renewal date on or after Aug. 1, 2012, and pharmacy coverage began on Aug. 1, 2012, regardless of the plan's renewal date as long as the group had pharmacy benefit contraceptive coverage prior to Aug. 1, 2012. For all other new or renewing plans, pharmacy and medical coverage becomes effective as of the first plan year, or the plan's first renewal date, on or after Aug. 1, 2012.

Members received pharmacy benefit contraceptive coverage Aug. 1, 2012, instead of waiting for the plan's renewal date if the plan renews after Aug. 1, 2012. Because this coverage is required for all plans that are not grandfathered or religiously exempt (including temporary safe harbor), we provided this pharmacy benefit contraceptive coverage early (if the plan renews after Aug. 1, 2012).

Are all contraceptives covered at 100 percent under the expanded women's preventive care services benefit?

No. While all FDA-approved methods are covered without cost-share under the health reform law, that does not mean all contraceptives. The methods covered by the pharmacy benefit are hormonal (e.g. birth control pills), barrier (i.e. diaphragms) and emergency contraceptives (i.e. "morning after" pills). UnitedHealthcare provides Tier 1 contraceptives for each method without cost-share. Review your Tier 1 prescription drug list for specific types and brands that are covered.

Are contraceptives that are provided through a doctor's office, like Depo-Provera® covered without cost-share?

Contraceptives administered by a network doctor in a medical setting, such as sterilization and services to place/remove/inject contraceptive methods like Depo-Provera or IUDs, will be covered at 100 percent under the medical benefit of non-grandfathered plans and other plans that adopt the health care reform preventive care coverage. Some contraceptives, like birth control pills, are covered under the pharmacy benefit at 100 percent when filled at a network pharmacy. Because the effective date of coverage of preventive services under the medical benefit and the pharmacy benefit may differ, it is possible that some members may have coverage at 100% for contraception under the pharmacy benefit before they have contraceptive or sterilization coverage at 100% under the medical benefit.

Does the health reform law require covering abortion or abortion pills?

No. The health reform law does not provide for coverage of abortion/abortifacient drugs/abortion pills as a preventive service. The health reform law requires covering emergency contraceptive methods as prescribed. This includes certain "morning after" pills, such as Plan B One-Step® and ella®, which are FDA-approved emergency contraception.

Mammograms

How does UnitedHealthcare cover mammograms?

The health reform law requires coverage of screening mammography for women age 40 and older every 1-2 years without cost-share. UnitedHealthcare believes mammography is a critical tool for early cancer detection and does not impose an age or frequency limit on breast cancer screenings. We cover screening mammography for all adult women.

Out-of-Network Coverage

Are preventive services received outside the network covered at 100 percent?

The health reform law does not require that preventive care services received from out-of-network health care professionals be covered at 100 percent. If a plan does cover preventive services out of the network, a copayment, coinsurance and deductibles may apply (unless a state law otherwise requires first-dollar coverage). If a plan does not cover out-of-network preventive services, then preventive services received by out-of-network health care providers will typically not be covered.

Prescriptions and Medications

Are prescriptions or any medications covered without cost-sharing?

The health reform law provides guidance to doctors around counseling and use of certain medications (e.g., aspirin to prevent cardiovascular disease, folic acid for pregnant women, and iron and fluoride supplements for children), but the medications are not covered without cost-sharing. We do not cover over-the-counter drugs or prescription strengths of any of these drugs without cost-share.

Prescriptions medications will be covered according to the patient's prescription drug plan.

Are flu shots covered at 100 percent?

Yes, the health reform law mandates that certain immunizations, including flu shots, are paid as preventive services without cost sharing when provided in a network doctor office for non-grandfathered plans. In some benefit designs, flu shots may be paid as preventive services when offered in other settings such as pharmacies. When flu shots in pharmacies are covered as a preventive service, they are paid as a medical benefit, rather than a pharmacy benefit.

Well-Woman Visits and Prenatal Care

Are postnatal visits covered as preventive under well-woman visits?

Well-woman visits, as defined by the health reform law, include visits to obtain the recommended preventive care services, including preconception counseling and prenatal care. Postnatal care to treat the mother after the baby is born is not covered as a preventive benefit, and cost-sharing may apply.

Are ultrasounds covered without cost-sharing under the women's preventive benefit?

While radiology services like ultrasounds may be part of prenatal care, they are not required under the health reform law to be covered at 100 percent. A copayment, coinsurance or deductible may apply for these services.

Is a pregnancy test considered a prenatal preventive service covered without cost-share?

No, a pregnancy test is not a preventive service, and cost-sharing may apply.

Prenatal, delivery and postnatal are often included in a global maternity fee. How will UnitedHealthcare only pay just the prenatal care at 100%?

Often maternity charges are billed together as a "global" maternity fee under a global obstetrical code. Under the health reform law, the prenatal portion of the visit must be covered as a preventive benefit to be paid without cost-share to the member, and the delivery and postpartum portion of the visit may be paid as a medical benefit with cost-share to the member.

Based on certain payment methodologies of the Centers for Medicare & Medicaid Services (CMS), UnitedHealthcare determined that 44 percent of the global OB code should be considered prenatal care and paid as preventive with no member cost-sharing, and 56 percent will be considered delivery and postpartum care which may include member cost-sharing. The appropriate fee will calculate based on this percentage. The process will be seamless to members, doctors and health care professionals.

Religious Employer Exemption and Temporary Enforcement Safe Harbor

What if an organization does not want to cover contraceptives?

The health reform law allows organizations a religious exemption or a temporary enforcement safe harbor for those who qualify. Qualified organizations may exclude contraceptive coverage from their health plans. The organizations requesting the exemption are solely responsible for their compliance with federal and state law regarding exemptions from contraceptive coverage requirements. The religious employer exemption and the temporary enforcement safe harbor are not available to fully insured plans in some states.