Those who have not met me yet, I am an International Board Certified Lactation Consultant (IBCLC) here in Germany. Our family is stationed in the Spangdahlem area with the Air Force.
I believe so deeply that mothers should be receiving lactation counseling at not out of pocket costs because it is a covered benefit with most health insurances. In this article I will be only talking about TriCare as this is the only insurance availble for our militarty families stationed overseas.
I have taken on the fight myself to try my absolute hardest to get lactation counseling reimbursed through Tricare here in Germany for about two years. There was a lot of red tape in my way, but I seemed to always find another approach to get around it. Or so I thought.
It is really hard to find a private practice lactation consultant like myself that is in network with TriCare in the United States. Most private lactation consultants only offer lactation care for cash pay rather than through insurances. I really wanted be different, I wanted to offer more than what was standard. In the US to be in network the IBCLC usually has to be a nurse or have another medical degree. Most of us do not hold medical degrees because or career field is in lactation not an addition to another degree. This is a loop hole most American insurances figured out. If they have restrictions on who can be in network by requiring a degree inflation to provide lactation care, then they usually won't have to pay for that service.
Overseas, the company that manages TriCare is International SOS. International SOS does not require providers to have any additional credentials or degrees outside of their chosen career. This was hopeful for me because that meant I did not need to be a nurse to be in network like it would be if I was in the US.
So I went on to start the process of becoming in network with TriCare through International SOS. The process was very time consuming but I was eligible to be in network except for one missing document. This document was German public health authorization for medical providers. Basically asking permision from the German public health office to allow me to practice in my field here. They could not provide me with this document because lactation consultants are insanely uncommon here in Germany. No one in those offices from Bitburg, Wittlich, or Kaiserslautern has ever head of a lactation consultant before. More than just that, they said it was not possible because this was not a profession here in Germany. There was no way they could give me medical provider authorization for an unrecognized profession. So this ended my journey on trying to be in network with Tricare.
I didn't let this stop my goals though, I continued to pursue it as an out of network provider. If you go onto the TriCare "find a doctor' directory and search any version of lactation consultant near Spangdahlem, there is no one listed. Per TriCare policy if an insurance covers a benefit such as lactation counseling but does not have an in network provider they have to cover the service from the out of network provider. This is called the Gap exception.
Tricare requires a referral to be placed for all speciality care prior to appointments. So i had about 6 women who called our base medical clinic to ask for a lactation referral. I really thought I had substantial ground to stand on with the gap exception. Lactation counseling is a medically neccessary service that should have been approved from TriCare. But none of them were. This lead me and the local Tricare office to investigate the reasoning.
Germany as a country does not cover lactation counseling through insurance. Their government has regulations in place that prevents any lactation care to be included in their health care system here (aside from the midwifery home visits in the postpartum periods.) As guests to this country we have to abide by local health authority regulations. Their regulations say it is not a recognized profession and it will not be coved by health insurance. The two main reasons why lactation is not covered here in Germany is: to be in network with tricare overseas you have to credential as a provider with International SOS. You can not credential with them without local publich health permission. Germany can not provide this permission for lactation consultants because its is not considered to be a medical profession. Then on the TriCare side, you can only bill for these services if you are also a nurse or hold another medical credential. These policies are the reason why it is so difficult to get insurance to cover lactation care here in Germany. Even for an international board certified lactation consultant (IBCLC) which is the gold standard for lactation care in the US.
It may be possible to receive lactation care coupled in with a post partum hospital stay or a baby well visit if you are lucky enough to have a lactation professional on staff at your MTF, these are far and few in between. But that is the limit for most Americans living here in Germany.
TriCare / International SOS has repeatedly expressed they cannot uphold the gap exception clause with me specifically because I do not hold an RN or other medical degree, unfortunately. It really has been a long road trying every which way to make this work.
There may be hope in the future for more accessible lactation coverage in overseas locations starting in Jan. 2025 per the Child Birth and Breastfeeding Support policy. Read more on this here. https://www.tricare.mil/Plans/SpecialPrograms/CBSD#:~:text=TRICARE%20will%20cover%20up%20to,get%20one%20visit%20during%20birth.
References:
Elizabeth Hormann, Elien Rouw, Veronika Scherbaum. The High Cost of Half Hearted Breastfeeding Promotion in Germany. PMC. 2015. doi: 10.1186/s13006-014-0022-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940918/