Donor Breast Milk Coverage for Infants Under 12 Months, CR 113541

Dec 22, 2022

On January 1, 2023, MaineCare will add coverage for donor breast milk (CPT code T2101 - Human breast milk processing, storage, and distribution) under Section 90, Physician Services, and Section 45, Hospital Services, in accordance with Maine P.L. 2021, Ch. 708 (L.D. 85), An Act Concerning MaineCare Coverage for Donor Breast Milk. Donor breast milk provided under Section 90 requires prior authorization (PA), which providers must request using the relevant PA Sheet from the MaineCare HealthPAS Online Portal. You can view the PA Sheet by logging into your Trading Partner Account and following this pathway: >MaineCare Information>Manual, Forms, and Criteria Sheets. Donor breast milk provided under Section 45 does not require a PA but must meet the criteria below. The reimbursement rate for donor breast milk is $4.11 per ounce.  

MaineCare covers donor breast milk for infants under 12 months when a physician, physician assistant, or advanced practice registered nurse orders it and when infants meet the following criteria:  

1. The infant is medically or physically unable to receive maternal breast milk or participate in breastfeeding, or the infant's mother is medically or physically unable to produce maternal breast milk in quantities sufficient for the infant; and at least one of the following: 

2. The infant: 

1. Was born at a birth weight of less than 1,500 grams; 

2. Has a gastrointestinal anomaly or metabolic or digestive disorder or is recovering from intestinal surgery and the infant's digestive needs require additional support; 

3. Is not appropriately gaining weight or growing; 

4. Has formula intolerance and is experiencing weight loss or difficulty feeding; 

5. Has low blood sugar; 

6. Has congenital heart disease;

7. Has received or will receive an organ transplant; or 

8. Has another serious medical condition for which donor breast milk is medically necessary. 

For questions, please contact Tiffany Norton.