I feel funny writing this…I am so excited about a new Tricare Insurance policy change! You read that right. I am excited about health insurance! TRICARE insurance at that. It’s not often that we TRICARE beneficiaries get to say this! So this is a good one!
On 18 March 2019, TRICARE Insurance changed its policy and now covers Banked Donor breast Milk (BDM)! And, honestly, it appears to be pretty decent coverage. Of course there are stipulations and fine print but I’m hoping this article, as well as a great article from Military Times, will help set you up for success if you are in need of Banked Donor Milk!
If you’re reading a From The Start, Postpartum Doula blog article for the first time, I’ll warn you that I like data points and research and I may be dressing up as an amateur journalist. This article is no exception. As part of my research for this article, I wanted to connect with my nearest HMBANA milk bank to ask how Tricare families can go about accessing this covered cost and several other questions. I had an amazing conversation with Pauline Sakamoto, the Executive Director of the San Jose Mother’s Milk Bank who was just as excited to talk to me as I was to talk to her. You’ll read more about our conversation later in this article. But first, let’s talk about the new policy.
TRICARE’s Banked Donor Milk Policy
Once I figured out how to find the new policy, it is pretty easy to read and, as far as medical documents go, it is fairly straight forward. There are still a few gaps in information and coverage as well as some areas left to interpretation. But, overall, it makes sense, and it appears to be good coverage.
I called TRICARE Claims and spoke with Amy. She was extremely kind, helpful, and honest with me about how this process works. She guided me as to how to find the policy manual online. She professionally and honestly answered as many of my questions as she could. I learned several things between my phone call with her and my own reading of the various policies, summarized below:
The new Banked Donor Milk policy is a subset of Chapter 8, Section 7.2, Medically Necessary Food, of the TRICARE Policy Manual (TPM) 6010.60-M, April 1, 2015, Chapter 8 (Other Services), Section 7.2 (Medically Necessary Food - For Dates Of Service On Or After December 23, 2017).
The BDM policy is effective 1 January 2019 and the official implementation date is 20 May 2019. This effective date is important for anyone looking to use this benefit immediately. I’ll explain more in a minute.
What’s covered and how does it work? The 5 W’s and an H.
The TPM referenced above details the covered benefit. I’ll share the highlights here.
In order for an infant to receive Banked Donor Milk (BDM), the infant must meet two (2) main conditions:
Infant’s own mother’s milk is contraindicated, unavailable due to medical or psychological condition, or mother’s milk is available but insufficient due to quality or quantity.
Infant has one (1) or more of a list of several conditions. These include birth defects, birth weight, metabolic/digestive disorders, organ transplant, formula intolerance, failure-to-thrive, and other serious conditions when BDM is medically necessary, plus more not listed. Full list is available at the TPM listed above, paragraph 126.96.36.199.
The TPM also specifically addresses the physical absence of the birth mother in extraordinary circumstances. To quote from the policy, “If the birth mother is unavailable due to the physical absence of the birth mother in extraordinary circumstances (i.e., adoption, maternal death, deployment of Active Duty Service Member (ADSM) mother), the own mother’s milk is considered to be unavailable for the purposes of this paragraph.”
Coverage is for as long as long as medically necessary, not to exceed 12 months of age (meaning, families can claim BDM anytime and for however long is necessary, up to baby’s 1st birthday)
Coverage shall be limited to no more than 35 ounces per day, per infant.
Policy was effective 1 January 2019 and will be implemented on 20 May 2019
WHERE: BDM must come through an accredited milk bank. Currently, TRICARE will only accept claims from and through Human Milk Banking Association of North America (HMBANA)-accredited organizations. These organizations are only in CONUS and Canada. HOWEVER, many of these organizations are more than happy to ship to overseas locations (I’ll tell you more about this below!!).
WHY: TRICARE doesn’t specifically tell us why they started providing this benefit but I’m going to go out on a limb here and speculate two reasons. First, breastmilk is the ideal food for newborns and infants and it appears TRICARE is doing its part to help provide breastmilk to infants who are unable to feed directly from the breast. Additionally, feeding breastmilk to newborns and infants has life-long implications which can also lead to reduced medical costs over time (heck, they are a business too).
Infants needing BDM require a prescription from a TRICARE authorized individual professional provider
Initial prescription shall describe quantity and frequency of the required BDM, and shall only be valid for 30 days. Each subsequent prescription shall describe the same and shall also only be valid for 30 days.
BDM provided during an inpatient stay shall be cost-shared the same as any other medical supply provided during an inpatient stay.
BDM provided on an outpatient basis shall be subject to the same copays and cost-sharing requirements as other outpatient medical supplies.
The policy also includes a few specific exclusions, so be sure to take a look at those before initiating your BDM claim.
Speaking of claim, let’s talk costs and reimbursements.
Cost and Reimbursement
I had a few questions about coverage, payments, claims, and reimbursement, so I pulled up TRICARE Reimbursement Manual 6010.61-M (TRM), April 1, 2015, Chapter 1, Section 39, which is a new section released as part of BDM inclusion. This is where we can find detailed information on “payment amounts and procedures for reimbursing BDM.”
Paragprah 4.3 of the TRM clearly states how much TRICARE will cover, per ounce. “Effective with the 2019 CMAC update, the national reimbursement rate for HCPCS code T2101 is $4.50 per ounce (one unit is equivalent to one ounce). This rate shall be wage-adjusted and updated annually by the same conversion factors used to update the annual CMAC file, and will be made available at http://www.health.mil/rates."
Ch. 8, Section 7.2, paragraph 3.8.11 of the TPM says, “BDM provided on an outpatient basis shall be subject to the same copays and cost-sharing requirements as other outpatient medical supplies.” This is our key link between the policy and coverage/reimbursement. Outpatient Medical Supplies (also deemed Durable Medical Equipment). BDM is considered a medical supply, for the sake of covered/reimbursable benefits. I swoon for charts and organized info, so here’s a handy chart of what is covered and what you can expect for a copay for each of the TRICARE plans:
Alrighty. We’ve covered cost of the BDM. But, we haven’t covered all the costs associated with this benefit. Shipping. Let’s talk about shipping.
I’ll be totally honest here - this is not something I feel confident about. Talking about shipping is getting in to insurance codes and, well, those just aren’t my jam! The TRM says this in paragraph 4.6 about shipping: “Reimbursement for HCPCS code T2101 includes the processing, storage, and distribution of BDM. Separate charges for shipping or other services are not separately payable.” So, is shipping part of “distribution”? If so, it looks like it’s covered under the code. If it’s not, and if it is a separate service (which I believe most are), it’s not a covered service. So, to adequately prepare you for this, I am fully under the impression that shipping of this BDM is NOT a covered service and the shipping costs will be paid out-of-pocket (though, check with your accountant because you may, I say again, may, be able to claim these as medical expenses). I certainly do not know the answer on this so if any of you out there know the answer, or when you find out, please let me know!
Info from TRICARE Claims
Now that you know all this (thanks for still reading, by the way!), I want to share a bit from my conversation with the amazing Amy.
As I mentioned above, the BDM policy is currently effective, though it is not implemented yet. This means, between now and 20 May 2019, we are all in a state of limbo. Be cautious of using the BDM policy. You can still use it because it is an effective, covered service so, with proper paperwork and documentation, you should eventually receive reimbursement. As of 21 March 2019, TRICARE Claims section has not received guidance or information on how to process these claims and how to handle this new coverage, so please proceed with caution. If you need BDM now, you will be caught in between the effective date and the implementation date.
My phone call with Amy clarified this a bit. She said that you can still submit your claim, no matter what. It may get denied, but as long as you submit it, that record will be created which should open the door for future reimbursement. You’ll just want to monitor the claim and once 20 May 2019 comes around, make sure you follow up with TRICARE regarding the claim.
Phew. There you have it. My research, phone call, and associated brain-dump regarding the new policy. Those with inquisitive minds, I’m sure you have questions! Feel free to ask me and I’ll do my best to clarify, find you regulatory answers, or provide you with the TRICARE phone number!
Now, how the magic happens. Especially how the magic happens in California.
Mother’s Milk Bank
As part of writing this article, I wanted to be able to include details for how Southern California TRICARE families can go about using this new benefit. So, I did as the TPM told and I searched on the HMBANA website for my nearest bank. To my surprise, the closest bank is Mother’s Milk Bank in my hometown of San Jose, CA (about a 6 hour drive). So, I initiated contact with Pauline Sakamoto, the executive director, and, after a bit of phone tag, we connected for a wonderful conversation about this long-overdue change to TRICARE’s coverages.
Pauline is simply amazing. She’s been in the lactation and breastmilk world for years. Decades, really. She has helped thousands of families along their breastfeeding/breastmilk journey and is just a ray of sunshine for these families. She explained many things to me, including Mother’s Milk Bank’s logistics, their pricing, and their operations. I was humbled when she repeatedly said how much Mother’s Milk Bank loved their military moms. She said, over the years, she has received hundreds of ounces of donated breastmilk from military moms and she is forever grateful for their efforts and reliability. I could literally hear Pauline’s smile as she spoke about military moms. She explained that she receives huge quantities of donated milk from military mamas all over the country, but especially from our Southern California military moms! Obviously, I was hooked!
Pauline shared a few stories of the military families they have had the chance to support over the past couple years. She told a few sad stories about how the families came to need BDM, but immediately warmed my heart when she admitted that Mother’s Milk Bank and these families were able to work together for a plan to ensure the children received the BDM, despite the cost and lack of TRICARE coverage.
She also shared that she sent milk from Mother’s Milk Bank to support a military family in Italy. True story…she drove from San Jose up to Travis Air Force Base and was able to get this shipment of milk onto a C-17 which was already scheduled to fly to Italy.
So when I say she was just as excited as me about this change in TRICARE coverage, I’m being totally serious. She gets it. She’s been chomping at the bit to become a TRICARE in-network provider. And now’s her chance!
Receiving BDM from Mother’s Milk Bank
I spoke with Pauline on Thursday, 21 March, just two days after the new policy was released, and Pauline said she already had a military mom contact her about the policy.
Pauline described how Mother’s Milk Bank typically does business. She told me, “Typically, a prescription is for about 24oz per day for a specific number of days, weeks, months. Best way to do this provide about 1-1.5 weeks worth of milk in the first shipment. Then it’ll up to about 2 weeks of milk because sometimes families freezers cannot hold that much milk. If prescription is for 24oz per day but baby only takes 8oz per day, they will work with us to keep ordering milk until prescription is exhausted. Avoids families hoarding milk then having to dump.”
I asked where she ships to, and, as you can guess from the C-17 pallet above, she said they ship anywhere and only ship overnight express. And they are a fast turn-around too. Pauline said “if the prescription comes Monday through Thursday, family will get milk the next morning.” She said that Mother’s Milk Bank, and all HMBANA banks for that matter, have a priority list and milk distribution flows (ha, pun intended) in accordance with the priority list.
Another amazing thing about Mother’s Milk Bank is their cost. This bank is able to provide BDM at $3.75 per ounce, which is a very low price. Pauline said they can afford to do this because of the awesome donors who provide such a tremendous volume of donated breastmilk. If their volume decreases, she indicated the price would have to go up.
You may recall from above how this process works from the TRICARE side, but Pauline also briefly described how receipt of BDM works from her side. She confirmed a family needs a prescription, their name and phone/email of family member to confirm address, will be asking for ID (tricare information), then make arrangements to ship. It’s a very simple process and it’s almost completely initiated from their website: www.mothersmilk.org/receive-milk.
Donating milk to Mother’s Milk Bank
Feeling inspired by this? Looking to become a breastmilk donor? If you are interested in donating breastmilk to Mother’s Milk Bank, first and foremost, God bless you. Seriously. You are amazing for even considering this. What a gift you are able to provide and thank you so much for thinking about this.
For those of us in Southern California, BreastfeedLA has a great webpage that describes milk depots and provides information about the four main, accredited depots in our area.
The first thing you’ll need to do is call on the toll-free number (1-877-375-6645) to make sure you qualify as a donor. Then a questionnaire will be emailed, faxed, or mailed for you to complete regarding your medical history. Finally, after your forms are approved, a free, small blood test will be needed for final approval. Once you’re approved and cleared to be a donor, Mother’s Milk Bank will provide you with free temperature-controlled shipping to the depots/facility, as well as providing you with free milk storage bags. Seriously, once you’re approved, there is no financial cost to your breastmilk donation! Visit Mother’s Milk Bank’s donor information page for more details.
As I close out this article and this research, I want to wholeheartedly thank Pauline and her staff for all of the work they do for this effort. I am so glad to be connected with her and Mother’s Milk Bank. Look for some potential events in the future that highlight military families and Banked Donor Milk!
I could not be more thrilled about this chance in TRICARE’s policy. There are several other changes I’d love to see (ahem, doula coverage!), but I’m just so excited to see this as a covered benefit. It may be a bit challenging over the next couple of months as TRICARE tries to get settled, but give it time and patience (and possibly repeat claims submissions) and it’ll happen.
I have a good feeling about this!
Kari Haravitch PCD(DONA)