Medicaid Coverage of Family Planning Benefits: Results from a State Survey
|Key Finding: Sterilization|
|Coverage of sterilization services varied by eligibility pathway. States must cover surgical and implant sterilization procedures for women under ACA Medicaid expansion, and all of the responding states reported that they cover these procedures in Traditional Medicaid as well. However, not all family planning expansion programs cover these services.|
This survey inquired about states coverage of sterilization procedures for women (tubal ligation and non-surgical essure) and men (vasectomy). As with FDA-approved reversible methods, the ACA requires coverage under the ACA Medicaid expansion to include surgical and non-surgical sterilization procedures for women. The requirement does not apply to vasectomy for men.
Federal Rules for Payment of Sterilization
Federal funds can only be used to pay for the sterilization of an individual when:
a) The individual is at least 21 years old at the time consent is obtained;
b) The individual is not a mentally incompetent individual;
c) The individual has voluntarily given informed consent in accordance with all the requirements prescribed in §§441.257 and 441.258; and
d) At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.
Source: 42 CFR §441.253
The federal government requires states to cover sterilization procedures only when certain conditions are met. These requirements are intended to protect against coercive practices that had historically forced sterilizations upon marginalized groups, including low-income women, women with disabilities, women of color, and incarcerated women.1 Protections against these practices include requiring women to sign an informed consent form at least 30 days prior to a procedure as well as prohibition of federal matching funds for the sterilization of a mentally incompetent or institutionalized individual.
Most states with a Family Planning waiver or SPA also cover the procedures for women (Table 13), but there are exceptions. Ohio and Oregon do not cover tubal ligation (neither general nor post-partum) in their family planning programs. Connecticut, Georgia, Missouri, and Mississippi do not cover tubal ligation performed post-partum in their family planning programs, with Georgia noting that pregnant women are not enrolled in the state’s family planning waiver.
Although vasectomy is not a required benefit, all but two of the surveyed states covered this service for men. The District of Columbia and Hawaii, do not provide the benefit in their ACA Medicaid expansion programs. In Michigan, Missouri, Wyoming, Georgia and Maryland, only women are enrolled in their family planning waivers so they didn’t cover vasectomies. Ohio’s’ family planning SPA included men, but also did not cover vasectomies.
In the survey, three states noted utilization controls. North Carolina noted that only one procedure is allowed per lifetime. Kentucky requires prior authorization for vasectomies. Alabama will not pay for family planning services after a sterilization procedure has been conducted and also requires prior authorization for Essure.
|Table 13: Number of States Covering Sterilization Procedures, by Type of Program|
|Family Planning Waiver/SPA
|ACA Medicaid Expansion
|Tubal Ligation Post-Partum||41||17||Required|
|Tubal Ligation General||41||21||Required|