The Defense Health Agency (DHA) has updated its Tricare policy manual to clarify what types of breast pumps and supplies are covered by the Defense Department's health program.
The changes affirm coverage of breast pumps for new mothers and adoptive mothers, an initiative that began in late 2014, and allow expecting moms to access the benefit starting at the 27th week of pregnancy, or when the baby is born, if premature.
But the revised policy, announced Monday, limits coverage of breast pump kits to one per birth and excludes those considered to have luxury features, such as smartphone connectivity, expanded rechargeable batteries, fancy tote bags, car adapters and more.
The change follows a Defense Department Office of Inspector General report released last April that found the department paid $16.2 million more than it should have for electric breast pumps and replacement parts.
In some cases, the DHA had paid as much as $1,400 for a breast pump that could be purchased in a store for less than $200. The overages occurred, the IG found, because the Tricare policy allowed users to order a pump directly from a medical supply company and bill Tricare, or to buy a pump at a store and submit the receipt.
The investigation noted that the DHA should have required Tricare contractors to use suppliers with fixed, negotiated rates.
Now, pumps must be purchased from a Tricare-authorized provider and only replacement supplies considered essential for breastfeeding will be reimbursed. Patients can still purchase their own breast pump and supplies and request reimbursement, but there will be a maximum reimbursement rate, to be listed in the Tricare Reimbursement Manual.
Also, under no circumstances can patients purchase a breast pump kit that includes a pump and all supplies and submit reimbursement claims for individual components, according to the new policy.
"Unbundling of a breast pump kit for the purposes of billing items individually to maximize reimbursement is considered an abusive billing practice," the policy states.
According to the IG, the Pentagon overpaid for breast pumps more than 90 percent of the time under the old policy, 54,006 out of 59,241 purchases. It overpaid 57 percent of the time for replacement parts.
Failure to heed the new policy could result in out-of-pocket expenses for families, according to the policy update.
The new policy allows only the breast pump and the following replacement parts without an additional prescription: two bottles and caps or locking rings once a year after a birth event; one replacement power adapter per birth event and none within the first 12 months; 12 valves or membranes; one set of flanges per birth event; one set of tubing; and 90 breast milk bags every 30 days after the birth.
The caps placed on breast pump purchases by Tricare are as follows: for personal use, $312.84 in the U.S. and $500 overseas; for hospital grade (as required by a doctor), $1,501.65 in the U.S. and $3,003.30 overseas.
-- Military.com reporters Amy Bushatz and Richard Sisk contributed to this report.
-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter at @patriciakime.
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