Medicaid Coverage of Family Planning Benefits: Results from a State Survey
The analysis of state responses to this survey found that overall most states cover a broad range of prescription contraceptive methods in their full scope traditional Medicaid program, their full scope ACA Medicaid expansion, and the family planning expansion programs. Thirty-six of 41 surveyed states report that they cover all prescription contraceptives for women through their full scope programs. While states are not required to cover all methods under all pathways, most do. However, there is more variation between and within states for coverage of over-the-counter contraceptives, including condoms and Plan B emergency contraception pills. In some cases, when states provide coverage, it is only with a prescription which can limit access to these safe and effective methods.
Under traditional Medicaid, many screening and preventive services that are considered family planning “related services”, such as screening for partner violence and preventive therapies for breast cancer for women at elevated risk are optional. While coverage is provided for many women who qualify for the full scope pathways (traditional Medicaid or ACA expansion), coverage is less consistent for women who qualify for family planning expansions programs (SPA or Waiver). These are services that often allow providers to address underlying health and personal issues that affect sexual and reproductive health for women and men; limited reimbursement options mean that many will not get these services because providers do not have a way to charge for this care. This is not an issue that is unique to family planning and has long plagued the health care system for a broad array of preventive health care issues.1
The survey also finds that several states are actively working to promote access to LARC contraception methods. Most states provided coverage for the different types of IUDs that are available under all of their pathways and without utilization limits such as prior authorization or step therapy. Use of LARCs has increased significantly in recent years and the provider community has been encouraging greater use. Most recently, the American College of Obstetricians and Gynecologists endorsed broader provision of LARC methods postpartum.2
However, there are a number of financial and administrative disincentives that have made it challenging for clinicians to facilitate access to LARCs for women who want them. Policies including the integration of the cost of postpartum LARC insertion with the global maternity fee, low reimbursement levels, and administrative requirements can make it difficult for providers to retain a stock of IUDs. Given that Medicaid finances roughly half all birth in the US, state Medicaid policy on reimbursement of post-partum LARCs has the potential to broaden access to these effective methods for women who desire them. An April 2016 bulletin from CMS outlines a number of options for states to facilitate the use of post-partum LARC, including: increasing reimbursement, unbundling post-partum LARC insertion from the typical maternity care global fee, reducing administrative and logistical barriers to stocking IUDs, and providing them the same day a patient visits her provider.3 The survey finds that a number of states are providing payment separate from the maternity fee for postpartum LARCs, a change that has likely taken place in recent years as documented by other research.4
Medicaid enrollment has risen significantly since the ACA’s passage and could further increase if all states take up the ACA option to expand the program to all individuals living below 138% of the poverty level. Short of that, some of the states that have chosen not to expand full scope Medicaid have opted to establish family planning programs through Medicaid waivers or SPAs. These programs offer access to some family planning services, particularly contraceptives, but often not to the same degree as full scope Medicaid. Access to the full range of contraceptive methods as well as related family planning services has become a standard of comprehensive health care for women and men in their reproductive years.5 As enrollment in the Medicaid program continues to grow as a result of the ACA, coverage of family planning services under Medicaid will continue to be a significant force in shaping access to sexual and reproductive health services for low-income women and men in years to come.Managed Care and Family Planning Services Appendices