New York State Minimum Breast Pump Specifications for Medicaid Reimbursement

Minimum Breast Pump Specifications for E0602 - Breast Pump, Manual

The manual pump must:

  • Not be a bulb-type manual pump.
  • Have a suction source that is independent of the collection container and the pump cylinder cannot be used as a milk-collecting container.
  • Be packaged pre-assembled with all parts necessary for pumping with a minimum of one hand and be intended for a single user.
  • Be lightweight and portable requiring no electricity.
  • Have safety precautions to prevent suction from getting too high, > 250 mm Hg.
  • Have a comfort cushion and spring or similar for easier hand pumping.
  • Include breast flanges that are either adjustable/flexible or come in at least two (2) sizes to accommodate different breast sizes with no sharp edges.
  • Include a collection bottle of four to six ounces with a spill-proof cap and standard-size opening, and be bisphenol-A (BPA) and DHEP-free.
  • Contain collection bottle(s) and flanges made of medical grade quality to allow for repeated boiling and/or dishwasher cleaning which are scratch resistant and non-breakable.

The manual pedal pump must:

  • Be an easy-to-assemble wooden pedal pump which requires no electricity and is powered by the leg and foot muscles. This pump can be useful for mothers with compromised hand or arm movements.
  • Include an express spring for easier use.
  • Work with a double pumping collection kit.

Minimum Breast Pump Specifications for E0603 - Breast Pump, Electric

The electric personal use/single-user pump must:

  • Be lightweight and portable. The total weight of furnished assembly should not exceed 10 pounds.
  • Be packaged pre-assembled with all parts necessary for pumping. Assembly includes but not limited to pump motor unit, minimum 5 feet-long electric cord, and double pumping collection kit.
  • Operate on a 110-volt household current and be UL listed.
  • Have an adjustable suction pressure between 50 mm Hg and 250 mm Hg at the breast shield during use; a suction range just at the low or high end of the range is not acceptable.
  • Have an automatic mechanism to prevent suction greater than 250 mm Hg when used according to manufacturer's instructions to prevent nipple trauma.
  • Have a mechanism for automatic release of suction for safety.
  • Have variable/adjustable cycling not less than 30 cycles per minute; one fixed cycling time is not acceptable.
  • Have single and double pumping capacity and capable of maintaining a consistent vacuum (no pressure change) as the collection container fills regardless of the container size and whether single or double pumping.
  • Have double pumping capacity which is simultaneous, not alternating.
  • Have a visible breast milk pathway and no milk is able to contact the internal pump-motor unit parts at any time when the product is used per manufacturer instructions.
  • Include breast flanges that are either adjustable/flexible or if rigid, come in at least two (2) sizes to accommodate different breast sizes with no sharp edges.
  • Include a collection bottle of four to six ounces with a spill-proof cap and standard-size opening, and be bisphenol-A (BPA) and DHEP-free.
  • Include a durable soft-sided carrying case with a storage compartment to hold pumping accessories and an insulated cooling compartment including freezer packs for storing expressed breast milk; this is recommended especially for women returning to work or school.
  • Include a battery option and adapter that can be used as an alternate power source other than electric; this is recommended for flexibility of pumping.

Minimum Breast Pump Specifications for Single-User/Multi-User* Double Pumping Kits

*Use with hospital grade rentals.

The kit must:

  • Include breast flanges that are either adjustable/flexible or if rigid, come in at least two (2) sizes to accommodate different breast sizes with no sharp edges.
  • Be packaged pre-assembled with all accessories necessary for pumping two breasts simultaneously or only one breast manually.
  • Include at least two collection bottles of four (4) to six (6) ounces with a spill-proof cap and standard-sized opening, and be bisphenol-A (BPA) and DHEP-free.
  • Contain collection bottle(s) and flanges made of medical grade quality to allow for repeated boiling and/or dishwasher cleaning which are scratch resistant and non-breakable.
  • Have durable tubing designed for long-term pumping use.
  • Design and materials of the furnished assembly shall allow viewing the breast milk pathway.
  • Include an adapter that can be used as an alternate power source other than electric; this is recommended and may come as part of pump assembly or pumping kit.

Minimum Breast Pump Specifications for E0604 - Breast Pump, Hospital Grade, Electric

The hospital grade electric (multi-user) pump must:

  • Must not exceed 12 pounds including carrying case.
  • Operate on a 110-volt household current and be UL listed.
  • Have a visible breast milk pathway and no milk is able to contact the internal pump-motor unit parts at any time when the product is used per manufacturer instructions.
  • Have an adjustable suction pressure between 30 mm Hg and 250 mm Hg at the breast shield during use; a suction range just at the low or high end of the range is not acceptable.
  • Have an automatic mechanism to prevent suction greater than 250 mm Hg when used according to manufacturer's instructions to prevent nipple trauma.
  • Have a mechanism for automatic release of suction for safety.
  • Have variable/adjustable cycling not less than 30 cycles per minute; one fixed cycling time is not acceptable.
  • Have double pumping capacity which is simultaneous, not alternating.
  • Include a pumping kit for each personal user including durable tubing to connect to the pump and flanges, and have single and double pumping capacities.
  • Include a carrying case made of durable, washable materials for the pump-motor assembly and pump kit accessories; this is recommended if the pump needs to be portable.