Childbirth and Breastfeeding Support Demonstration
Tuesday, December 21, 2021
On Jan. 1, 2022, TRICARE will allow for certified labor doulas, lactation consultants and lactation counselors – currently excluded as TRICARE-authorized provider types under the TRICARE benefit – to provide reimbursable care to TRICARE beneficiaries under its Childbirth and Breastfeeding Support Demonstration. Please visit our Maternity Care benefit page for details on benefits, provider requirements and reimbursement. We will be updating our network directory to include these provider types. Beneficiaries and providers can visit www.tricare-west.com or contact us should they have questions about how to locate or nominate participating providers.
Key things to know:
Benefit coverage
- Up to six sessions of breastfeeding (lactation) counseling from a certified lactation consultant or counselor (six total, whether rendered under the demonstration or the TRICARE basic benefit by a TRICARE-authorized provider such as a physician, physician assistant, nurse practitioner, certified nurse midwife, registered nurse, outpatient hospital or clinic).
- Up to six visits by a certified labor doula (CLD) services before or after giving birth for pregnant beneficiaries who are at least 20 weeks and under the care of a TRICARE-authorized provider (for example, obstetrician, certified nurse midwife, etc.), as well as one continuous labor support encounter during the birth event.
- CLD services for beneficiaries who give birth at a military hospital or clinic are excluded from the demonstration.
Referrals
TRICARE beneficiaries do not need a referral for services under the demonstration. For TRICARE Prime beneficiaries, Point of Service charges may apply for care received by non-network providers without a referral.
Reimbursement/billing details (view current rates at www.health.mil/rates)
- Individual lactation counseling sessions: CPT® 99401 (15 min.); 99402 (30 min.); 99403 (45 min.); 99404 (60 min.)
- Group lactation consulting: CPT 99411 (30 min.) and 99412 (60 min.)
- Antepartum and postpartum visits: CPT 99509 (untimed, up to six combined antepartum and postpartum visits)
- Continuous labor support visits: CPT 59899 (untimed, one per birth event)
CPT® is a registered trademark of the American Medical Association. All rights reserved.
Certified labor doula services not personally performed will not be reimbursed. The provider’s National Provider Identification (NPI) number must be on all claims. Cost-shares, copayments and deductibles don’t apply to covered breastfeeding/lactation counseling services (see Point of Service note above).
Provider requirements
We are accepting network and non-network providers for participation. Lactation counselors, lactation consultants and labor doulas must meet the certification requirements outlined in the TRICARE Operations Manual, Chapter 18, Section 11 in order to be reimbursed under the demonstration. Providers interested in joining the TRICARE West Region network may contact us for additional information (additional network requirements apply). Existing network groups who have these provider types should notify us via an updated roster. Non-network applications are available on our “Non-Network Provider” forms page.
