MATERNITY

When ‘Covered’ Doesn’t Mean ‘Received’

3 major gaps in maternal homecare & how to close them

By Casey Hite

Maternal health outcomes are as influenced by pre- and post-partum care performed at home as they are by time spent in a clinical setting. The pregnancy and postpartum windows are supposed to be some of the most beautiful times for a family as they navigate recovery and infant feeding and care, all while working in a few hours of sleep. Unfortunately, many families also spend this valuable time struggling to decode complex insurance rules, documentation requests and timing constraints that were not designed with real-life variability in mind.

As CEO of Aeroflow Health, I have a bird's-eye view of how health insurance is used to get essential durable medical equipment (DME) to the patient. But my full system-level view also shows me a stubborn truth: Having coverage is not the same thing as receiving care. Given my visibility into this recurring issue, it is my responsibility to call it out and do what I can to create easier pathways to health care access.

There are three patient-outcome lenses that define what “turning coverage into care” means for successful home-based maternal care: access, continuity and equity.

Access makes the path from eligibility to delivery understandable and achievable for all patients, so they actually receive what their benefits promise.
Continuity aims to support families both during pregnancy and after birth into the postpartum period through education, supplies and follow-up touch points that fit into the daily realities of parenthood.
Equity is achieved by reducing non-clinical barriers such as language, transportation, geographic location and administrative burden so the most vulnerable patients are not falling through the system's cracks.

Gaps Stop Patients From Getting Maternal Health Care

Because maternal benefits are administered through a patchwork of state-based Medicaid rules, managed care policies and operational systems, the patient experience can hinge on timing rules and administrative constraints they never see coming or even know about. The confusing nature of the process is what led our organization to prioritize simplifying and streamlining DME access for patients more than a decade ago. Here are the traditional types of gaps.

ONE

Time Range of Support

The first gap we’re working to solve is that breastfeeding support should begin during pregnancy and continue through the postpartum period. The U.S. Preventive Services Task Force recommends providing interventions or referrals before and after birth to support breastfeeding and also notes that optimal behavioral counseling interventions include both education and ongoing support. The World Health Organization suggests that educational interventions during pregnancy, such as peer counseling, lactation consultation or formal breastfeeding education, can extend breastfeeding duration from a minimum of six months to over two years, with other safe foods woven into the child's diet.

TWO

Frequency Limits

The second gap is in the preset frequency limits, which are set by insurance providers and do not fully reflect real-world life cycles and needs. Even when a patient has a clear benefit to use, the frequency limits (which are often multiple years for postpartum equipment) can restrict access in ways that do not clearly align with medical need, pregnancy spacing or changes in clinical circumstances.

Policies vary widely by state. In Delaware and Virginia, coverage for the health care common procedure coding system code E0603, a standard electric breast pump, is limited to one pump every three years. Michigan allows one every five years. New York Medicaid caps coverage at two pumps over a lifetime. These time limits do not always reflect how families actually grow or how care is delivered in real life. The bigger issue is that patients experience these limits as a hard no, even when their circumstances change.

THREE

Prior Authorization

Lastly, there is a quieter barrier that is felt internally by health care organizations: the operational rules embedded in prior authorization (PA) workflows and claims systems. Correcting system-assigned PA details often requires a formal revision process rather than a simple edit. In some state systems, prior authorization details cannot be easily adjusted once submitted, meaning that small administrative errors can result in equipment not being distributed within narrow date windows. When that happens, the patient ultimately bears the consequences. At the end of the day, the patient doesn't care whether the barrier to their care is a policy or a system issue—they just experience delays, confusion and incomplete follow-through.

Gaps Impact the Most Vulnerable Patients

Operational hurdles and inconsistencies in care do not impact all patients equally. They disproportionately affect families with limited time, limited transportation flexibility, limited health literacy support and fewer opportunities to try again after a delay. Even though the benefit exists, this is how the structural variation quietly becomes inequity.

Homecare organizations will always compete with each other, but we should not compete over whether patients can access basic maternal supports. We must improve patient outcomes while reducing administrative waste across the board.

The first step is to align the coverage timing with evidence-based care, ensuring that prenatal and postpartum support and supplies are available when they are clinically most useful to the patient.

Next is narrowing down the extreme variation in timing, frequency limits and documentation burden created by the state-by-state volatility in benefit design, which creates inequitable access to care. Many operational rules create system constraints that then bring completely avoidable delays; we should work as an industry to modernize these PA correction pathways.

Lastly, we should be measuring access, not just utilization by tracking timeliness, abandonment and patient effort as indicators of whether coverage is actually translating to care.

Ultimately, as homecare organizations, we should be using our understanding of the maternal journey to advocate for a maternal homecare ecosystem where covered actually means received for every patient nationwide without requiring them to become insurance experts during one of the most demanding seasons of their lives.

Casey Hite serves as Aeroflow Health's CEO and is a seasoned health care executive with a strong background in health care operations, strategy and technology. With more than 20 years of experience in the health care industry, Hite has a deep understanding of the challenges and opportunities facing health care organizations. Visit aeroflowbreastpumps.com.