Insurance Circular Letter No. 5 (2018)

May 22, 2018


All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, and Municipal Cooperative Health Benefit Plans


Health Insurance Coverage for Comprehensive Lactation Support Services, Including Counseling, Education, and Breastfeeding Equipment and Supplies

STATUTORY AND REGULATORY REFERENCES: N.Y. Insurance Law §§ 3216, 3221, and 4303

I. Purpose

This circular letter provides guidance to insurers authorized to write accident and health insurance in this state, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to Insurance Law § 1124, and municipal cooperative health benefit plans (collectively “issuers”) regarding New York state requirements for health insurance coverage of comprehensive lactation support and counseling and breastfeeding equipment and supplies. Issuers must strictly comply with all existing statutory and regulatory requirements for providing this coverage.

II. Discussion

Insurance Law §§ 3216(i)(10)(A)(ii), 3221(k)(5)(A)(ii), and 4303(c)(1)(B) require issuers that deliver or issue for delivery policies or contracts providing hospital, surgical, or medical coverage to provide coverage for maternity care covering, among other things, parent education and assistance and training in breast or bottle feeding while the mother is receiving inpatient care. In addition, Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers in New York with respect to any such policy or contract, except for grandfathered health plans1, to provide coverage for preventive care and screenings, including comprehensive lactation support services, at no cost-sharing.

The scope of New York’s coverage requirements set from the fact that the Insurance Law requires, among other things, coverage for evidence-based care and screenings as set forth in guidelines by the Health Resources and Services Administration (“HRSA”), as well as evidence-based items or services for preventive care and screenings with an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”). Therefore, all of the services discussed below must be covered in policies or contracts providing medical, major medical or similar comprehensive-type coverage except for grandfathered health plans.

HRSA. The HRSA guidelines require coverage for breastfeeding support and counseling, including equipment, with no cost-sharing. The HRSA guidelines effective on or after August 1, 2012 recommend comprehensive lactation support and counseling by a trained provider during pregnancy and in the postpartum period and the coverage of costs for breastfeeding equipment2 in conjunction with each birth.3 Under the HRSA guidelines, the coverage extends for the duration of breastfeeding. In addition, HRSA guidelines recommend, for plan years beginning on or after December 20, 2017, comprehensive lactation support services (including counseling, education, and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum period to ensure the successful initiation and maintenance of breastfeeding at no cost-sharing.4

USPSTF. Similarly, the USPSTF recommends, with a “B” rating, interventions during pregnancy and after birth to promote and support breastfeeding effective for plan years that began on or after October 23, 2010.5 According to the full recommendation statement, interventions may include multiple strategies, such as formal breastfeeding education for mothers and families, and direct support of mothers during breastfeeding observations. These interventions may be accomplished during pregnancy, at the time of delivery, and after birth while breastfeeding is underway. In addition, the USPSTF recommends breastfeeding interventions during pregnancy and after birth to support breastfeeding for plan years that begin on or after October 25, 2017.6 According to the full recommendation statement, breastfeeding interventions include professional support provided by a medical professional, the provision of supplies including nursing bras and breast pumps, peer support, and formal education. These interventions begin during pregnancy and continue during the early life of the child, and may include the woman’s partner.

The coverage under the New York Insurance Law described above is independent of federal law.

III. Conclusion

In accordance with Insurance Law §§ 3216(i)(10)(A)(ii), 3221(k)(5)(A)(ii), and 4303(c)(1)(B), all issuers in New York must provide coverage for parent education, and assistance and training in breast and bottle feeding while the mother is receiving in-patient care, in any policy or contract delivered or issued for delivery in New York. In addition, in accordance with Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3), all issuers with respect to any such policy or contract, except for grandfathered health plans, must provide comprehensive lactation support services, including breastfeeding equipment and supplies, at no cost-sharing. These requirements in the Insurance Law are independent of the requirements in federal law. Coverage for lactation support services is an essential feature of maternity care in New York, and the Department of Financial Services will continue to ensure full compliance with these important consumer health protections.

Please direct any questions regarding this circular letter to Colleen Rumsey, Supervising Insurance Attorney, by mail at New York State Department of Financial Services, Health Bureau, One Commerce Plaza, 19th Floor, Albany, New York 12257, or by email at [email protected].

Very truly yours,

Lisette Johnson
Bureau Chief, Health Bureau

1 A “grandfathered health plan” means coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e). Ins. Law §§ 3216(i)(17)(F), 3221(l)(8)(G), 4303(j)(4).