Updated 10-3-2022 Connecticut WIC Program Manual

WIC 300-12 SECTION: Nutrition Services SUBJECT: Guidelines for Breast Pump Issuance POLICY When appropriate, the WIC Program provides manual and personal use electric breast pumps to participants. WIC local agency staff should follow breast pump issuance guidelines when providing breast pumps. This policy covers: • Coordination with HUSKY Health for Durable Medical Equipment (DME) Breast Pump Benefits (Connecticut Medicaid) o Guidance for Managing Issues with HUSKY Health Provided Breast Pumps o Issuing a WIC Breast Pump when a HUSKY Health Breast Pump Malfunctions/Breaks o Guidance for Obtaining Different Size Flanges though HUSKY Health o How to Obtain Different Size Flanges from WIC • Minimum Criteria for WIC Breast Pump Issuance • Guidelines for Issuance of a WIC Breast Pump • Other Considerations • References Coordination with HUSKY Health HUSKY Health covers manual breast pumps (E0602) and personal use electric breast pumps (E0603, AC and/or DC) with a health care provider’s prescription. HUSKY Health also covers hospital grade (multi-user) electric breast pumps. For members that require this type of breast pump, a prescription and prior medical authorization is required. Code E0604 should be used. At the time of this revision, Acelleron is a DME that may be able to provide multi-user (hospital grade) pumps to HUSKY members, but this is currently dependent on the location of the delivering hospital. Healthy Baby Essentials (HBE) is a DME can provide multi-user (hospital grade) breast pumps to any HUSKY members. Again, a prior authorization and prescription are necessary with a multi-user (hospital grade) pump rental. The HUSKY Health hospital grade breast pump policy can be found on the HUSKY Health webpage, www.ct.gov/husky click the providers tab, next at the bottom of the page click on Policies, Procedures and Guidelines, scroll down to find the Hospital Grade Breast Pumps link to review the policy. According to the United States Breastfeeding Committee’s Model Policy: Payer coverage of Breastfeeding Support and Counseling Services, Pump and Supplies there are varied situations where a multi-user, hospital grade pump would be the appropriate pump upon discharge from the hospital, which include the following circumstances listed below. Please consult the HUSKY Health policy above for more details on clinical coverage guidelines in Connecticut. • When the infant is premature at 24-34 weeks of gestation, and the mother is pumping breast milk, awaiting the baby’s ability to nurse directly from the breast, or • When the infant is premature at 35-37 weeks of gestation and continues to experience difficulty coordinating suck and swallow, and the mother is pumping breast milk awaiting the baby’s ability to nurse directly from the breast, or

Updated 10-3-2022 • For infants with cleft lip and/or palate who are not able to nurse directly from the breast, or • For infants with cardiac anomalies or any medical condition that makes them unable to sustain breast feeding due to poor coordination of suck and swallow or fatigue, or • For multiples (including twins), until breast-feeding at the breast is established consistently, or • When the mother has an anatomical breast problem, which may resolve with the use of a breast pump, such as inverted nipples or mastitis, or • For any infants for medical reasons who are temporarily unable to nurse directly from the breast, such as NICU babies, or during any hospitalization of the mother or baby which will interrupt nursing, or • When the infant has poor weight gain related to milk production and pumping breast milk is an intervention in the provider’s plan of care and infant has a documented weight loss of 7% or greater despite use of conventional breast pump. In most cases, the personal use, double electric breast pumps are ideal for individuals with an established milk supply. For example, a person returning to work or school with daily (8 hour) separations from their healthy infant(s). Before issuance of a WIC breast pump, WIC local agency staff must inquire if the WIC participant is eligible for an electric breast pump covered by HUSKY Health. If so, they should receive a prescription for an electric breast pump from the hospital or their health care provider (HCP). If a participant reaches out to a DME directly, the DME may assist the participant in obtaining the prescription from the HCP. The State agency realizes that from time-to-time situations arise where Husky Health members may run into difficulty accessing their HUSKY Health breast pump benefit. In these situations, the WIC nutritionist should exercise their professional judgment and critical thinking skills as to issue a WIC breast pump to preserve lactation. In instances where staff deviate from standard protocol to issue a WIC pump, documentation is required. As a reminder the State Breastfeeding Unit staff is available to discuss these situations if needed. WIC local agency staff should discuss the following information with participants planning to take advantage of the HUSKY Health breast pump referral/benefit OR as normal procedure for issuance of WIC electric or manual breast pumps • Advise participants to feed the baby on demand at the breast. • Counsel on frequent thorough removal of breastmilk as baby nurses, learning about their baby’s personality and nursing style, latch and position, realistic expectations about what the early postpartum breastfeeding experience will be like for them individually (hormone shift, discomfort from delivery, sleep deprivation) • Provide information on importance of support systems within their friend/family circle in addition to community support programs like WIC (and Peer Services if applicable), Lactation Consultants, La Leche League (LLL), reputable online support (for example USDA WIC Breastfeeding Support Learn Together. Grow Together), VNA services.

Guidance for Managing Issues with HUSKY Health Provided Breast Pumps

The Connecticut Department of Social Services cannot endorse any specific brand of breast pump. HUSKY Health members are therefore subject to what is available from the DME vendor. A specific brand of pump should only be dispensed if it is written on the prescription.

Updated 10-3-2022 At times, WIC participants do report problems with either obtaining HUSKY Health breast pumps or with the functioning of their HUSKY Health issued pump to WIC staff. Since these were provided as a benefit of HUSKY Health we can assist participants with rectifying their issues by referring back to their plan as follows.

The following information must be collected to best help our participants: • Member Name • HUSKY ID # for both mom and baby • Reason for requesting assistance or specific trouble with pump

Please refer to Guidance for WIC Staff regarding HUSKY Health Coverage of Breast Pumps to determine who to contact. This contact information is for WIC Staff Use only. Participants may be directed to call Member Services at 1-800-859-9889. Please copy the WIC State agency Breastfeeding Coordinators on any e-mail correspondence with the Community Health Network of Connecticut (CHN-CT) which is the State’s contracted health plan.

marilyn.lonczak@ct.gov lori.goeschel@ct.gov

In some cases when pumps have broken or malfunctioned, HUSKY Health issued a replacement. Further assistance can sometimes be received from the pump companies directly. Ameda ParentCare 1-866-992-6332 / 1-866-99-AMEDA ParentCare@ameda.com Hours of Operation: Monday - Friday 8:00AM– 5:00 PM, Central Standard Time (CST)

Medela Customer Service

1-800-435-8316 Hours of Operation: Monday-Friday, 7:30 AM – 5:00 PM, Central Standard Time (CST). http://www.medelabreastfeedingus.com/customer-service In most cases, participants would need to call for themselves to be advised by a representative.

Issuing a WIC Breast Pump when a HUSKY Health Breast Pump Malfunctions/Breaks

If/when this happens WIC staff should: 1. Determine if the pump is broken or some other reason is the cause i.e., in inappropriate use, faulty connections etc..., use the above guidance to help participant troubleshoot problems. 2. If the pump is defective, contact CHNCT at 1-800-440-5071 to see if a replacement can be ordered; if it can but there will be a wait of 1-2 weeks for a replacement, use professional judgment to determine the best course of action. 3. If necessary, issue a WIC personal use double electric breast pump. Document the rationale for decision made. 4. Call or e-mail State WIC Breastfeeding Coordinator or WIC Breastfeeding Peer Counseling Coordinator, if necessary.

Updated 10-3-2022 How to Obtain Different Size Flanges for HUSKY Health Provided Pumps

Often, participants may require different size flanges for HUSKY Health issued breast pumps. When this occurs, WIC staff should let the participant know to contact the DME that the pump was ordered from and/or the physician to obtain a prescription for the correct size flange. If the prescription comes from the physician, it should be forwarded to the DME provider.

The DME provider will submit a Prior Authorization (PA) request marked URGENT to CHNCT under the code E1399, as there is no HCPCS code for this item. CHNCT will expedite these PA requests (48 hour on average) if it is marked URGENT and with the explanation that the participant cannot properly express milk from the breast because the flanges included with the initial breast pump were an incorrect size.

As always, WIC Staff can refer HUSKY members to CHNCT Member Services at 1-800-859-9889. WIC staff can assist participants by contacting one of the CHNCT staff members directly during a WIC visit.

How to Obtain Different Size Flanges from WIC

If the participant is having difficulty receiving appropriate flanges from HUSKY or doesn’t have Husky, WIC staff can order different sized Medela and Ameda flanges from the WIC State agency. Orders need to be placed through the most current WIC order forms. Local agencies can keep a minimum number of flanges in stock.

Breastmilk Collection Bags

Effective October 1, 2022, HUSKY/Medicaid will cover up to 100 breastmilk collection bags per month, for Husky members. For individuals that need additional breastmilk collection bags, the Prior Authorization process is recommended.

Breastmilk collection bags can be ordered at the same time the breast pump is ordered OR can be ordered separately if needed with provider prescription or using the selected Durable Medical Equipment (DME) form/process. Participants should be directed to the DME provider for specific details.

The WIC program can also provide limited quantities of breastmilk collection bags, but the preferred route is through HUSKY insurance if applicable. Minimum Criteria for WIC Breast Pump Issuance As noted in the Breast Pump Issuance and Training Content Sheet, a primary goal of the WIC program is to support breastfeeding participants to meet their breastfeeding goals. In most cases the most effective method of breastfeeding is baby actively feeding at the breast. In situations where feeding at the breast is difficult for the dyad or not possible, breast pumps are effective tools to maintain (and in some cases establish) lactation. Using the following criteria and working with the WIC participant the WIC Nutritionist can determine the appropriate pump or pumps to achieve breastfeeding success.

Updated 10-3-2022 A manual breast pump may be issued to a breastfeeding participant who meets the following criteria: • Active WIC participant. • Has a documented reason why a manual breast pump is indicated. For example, including but not limited to, expression of milk prior to latching baby, short separations between mom and baby, and to facilitate supplementation of mothers’ own milk instead of formula, • After instruction, the participant demonstrates understanding of the use and care of the breast pump. An electric breast pump, may be issued to a breastfeeding participant who meets the following criteria: • Active WIC participant • The WIC Nutritionist must document the reason why a double electric breast pump is indicated. • The participant does not require a hospital grade pump. • Is not eligible for insurance coverage of an electric breast pump. If the participant is eligible, please document rationale of issuance. • After instruction, the participant demonstrates understanding of the use and care of the breast pump.

Guidelines for Issuance of a WIC Breast Pump

• A manual pump is recommended for a person who is separated from their infant 20 hours per week or less. However, each situation requires individual consideration. • Electric breast pumps (personal use) are ideally intended for a breastfeeding participant with an established milk supply who is returning to work or school or have circumstances that warrant a pump i.e., separated from infant. • Issuance of a tailored food package is required based on amount of formula supplementation. In situations when the amount of formula given to the baby is less than the maximum limited breastfeeding food package, the nutritionist should explain the rationale behind the tailored package to the participant how this will preserve breast milk supply. When a full limited breastfeeding package is necessary for the participant to meet feeding goals, it is important that there is critical thinking and documentation. • A candidate for a breast pump should be willing to complete a survey* after issuance and using the breast pump. • A candidate for a manual breast pump should be willing to receive instruction regarding the assembly, use, care of the pump, and demonstrate her understanding of its assembly, use and care. • A candidate for an electric breast pump should be willing to view an instructional video explaining the assembly, use and care of the breast pump. After viewing the video, they should demonstrate an understanding of its assembly, use and care • A candidate must read and sign the breast pump release form. When appropriate, a nutritionist may read the form to the participant.

*An on-line participant feedback survey was created and replaces the paper survey. All participants should be encouraged to take the on-line survey to provide feedback about the education provided to them by WIC staff on their breast pump. Results of the on-line surveys will be forwarded to local agency breastfeeding coordinators annually, in July. Discussion of results should be included in the annual local agency plan (LAP) submission.

Updated 10-3-2022

Other considerations

WIC local agency staff should be aware there are some participants who are uncomfortable bringing baby directly to breast and desire to pump their breast milk only. Research is emerging that prior trauma, i.e., either physical or sexual abuse1 may impact a woman’s ability to feed directly at the breast. Individual assessment of all breastfeeding participants is crucial to provide accurate information and referrals and to prevent incorrect use of pumps and other equipment.

For exclusively pumping participants, WIC local agency staff must review the signs and symptoms of plugged ducts and mastitis. Discussion about the intention to exclusively pump should also be addressed, with a focus on the difference between breast pumping and breastfeeding. More challenging situations should be discussed with the Breastfeeding Coordinator and fellow colleagues to incorporate a team approach to breastfeeding support and improve skills and knowledge of the entire group.

References Food and Drug Administration (FDA) Choosing a Breast Pump https://www.fda.gov/consumers/consumer- updates/what-know-when-buying-or-using-breast-pump FDA webpage: Purchasing Breast Pumps: https://www.fda.gov/medical-devices/breast-pumps/choosing-breast- pump United States Breastfeeding Committee, National Breastfeeding Center. Model Policy: Payer Coverage of Breastfeeding Support and Counseling Services, Pumps and Supplies. Washington, DC: United States Breastfeeding Committee and National Breastfeeding Center Rhode Island WIC Program, Procedure Manual Section 440.1, WIC Electric Breast Pump Distribution Medical Necessity US DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services. Medicaid Coverage of Lactation Services, Issue Brief; 2012. https://www.medicaid.gov/medicaid/quality-of- care/downloads/lactation_services_issuebrief_01102012.pdf California WIC Association, Opportunities for Nutrition and Breastfeeding Interventions Under Health Care Reform - Brief, May 2012. California WIC Association, Ramping Up for Reform - WIC Breastfeeding Toolkit, February 2012

1 Kendall-Tackett, K. Breastfeeding and the Sexual Abuse Survivor. Journal of Human Lactation. 1198, Vol 14, 125-130.