Filling the need for trusted information on national health issues…

Medicaid Coverage of Family Planning Benefits: Results from a State Survey

Managed Care and Family Planning Services

Key Finding: Managed Care and Family Planning Services
Most of the responding states have capitated contracts that include family planning in the capitation rate. Just over one-third of these states explicitly address potential utilization controls on family planning services in the contracts.

Managed care is now the predominant delivery system for Medicaid in most states. Over three in four women of reproductive age covered by Medicaid are enrolled in managed care arrangements.1

For MCO enrollees, ensuring that federal family planning requirements are met can present special challenges. For example, while MCOs typically limit beneficiaries to a contracted network of providers, in the case of family planning this is not allowed under the federal “freedom of choice” policy. Beneficiaries are entitled to see any Medicaid provider for family planning care, but may not be aware of this right. Some providers have also reported difficulty receiving reimbursement if they are not part of an MCO network. In capitated arrangements, it can also be difficult to know whether the state is obtaining the higher 90% matching rate applicable to family planning services. This survey included questions that explore the role of capitated MCOs in providing family planning services to women enrolled in Medicaid.

Of the 41 states responding to this survey, 31 reported contracting with capitated MCOs and 29 of these states indicated that family planning supplies and services are always included within the MCO capitation rate (Table 18). Two additional states, New York and Texas, indicated that some or all family planning services are carved-out of MCO contracts only but for MCOs claiming a “conscience” or religious exemption from the requirement to provide family planning services.

Twenty-five of the 31 responding states with MCOs reported that they claimed the higher 90 percent federal matching rate (“FMAP”) for family planning services provided through the MCO while five states2 indicated that they did not.

Table 18: State Reporting on Capitated MCO Contracts
Yes No
State has capitated MCO contracts? (N=41) 31 10
State include family planning within capitation rates? (N=31)

29 – Always
2 – Sometimes

State claims 90% FMAP for family planning services provided through an MCO? (N=31) 25 6*
MCO states contract with MCO with religious exemption? (N= 31) 4 27
MCO contract addresses family planning utilization controls? (N=31) 11 20
* South Carolina was in the process of claiming 90% FMAP

In addition to New York and Texas, only two other states (California and Oregon) reported having contracts with MCOs having a conscience or religious exemption from the requirement to provide family planning services. Only California reported having a referral process for enrollees in these plans, requiring the MCO to arrange for the timely referral and coordination of family planning services and to demonstrate the ability to arrange, coordinate and ensure provision of services through referrals at no additional expense to the state. The MCO is also required to identify these services in its Member Services Guide.

Key Finding: Faith-Based Plans
California and New York, states with the most beneficiaries, also contract with faith-based plans that oppose some forms of contraception. While California reported that they have a process in place for referral for family planning services for the beneficiaries in these plans, New York did not report a referral practice.

States were also asked whether their contracts with MCOs explicitly address how MCOs can use prior authorization, step therapy or other medical management controls for contraceptives. Eleven of the 31 of the responding states with MCO contracts answered “Yes.” Of these, three states (Illinois, Massachusetts and Texas) indicated that their MCO contracts prohibit prior authorization requirements for contraceptives and Arizona reported that MCOs are “not allowed to create barriers to contraceptive utilization.” Conversely, Maryland indicated that prior authorization and quantity limitations are permitted and Delaware reported that MCOs are required to follow the state’s preferred drug list, which includes contraceptive agents. Three states (Illinois, Maryland and New Mexico) said that MCOs are required to cover all FDA-approved contraceptives. Appendix Table A10 provides additional detail for state managed care policies.

Cervical and Breast Cancer Services Conclusion

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.