Medicaid Family Planning Programs: Case Studies of Six States After ACA Implementation
Key Trends in Medicaid Family Planning
Based on the six states as case studies, a number of key trends in Medicaid’s role in family planning were identified, including: the role of Medicaid family planning programs now that many people have coverage through full-scope Medicaid and Marketplace plans; eligibility and enrollment changes brought about by the ACA; growing interest in LARC; access to services, and the intersection between family planning services and broader delivery system reform. To a notable degree, interviewees based observations of their personal experiences, reflecting a dearth of state-specific data on how women access family planning services, the providers that they use, the type of family planning services that are most common, the role of managed care plans in providing family planning services, and the cost-effectiveness of family planning programs.
Role of Family Planning Programs
Nationwide, states that had Medicaid family planning programs prior to passage of the ACA have generally elected to maintain them, reflecting a belief that they still have an important role to play for low-income women. In non-expansion states, the decision to maintain a family planning program is a relatively easy one. As interviewees in Alabama, Missouri and Virginia explained, their programs provide important family planning services for women who otherwise do not qualify for Medicaid or who may find Marketplace coverage unaffordable. Alabama and Missouri simply maintained their existing waiver programs while Virginia opted to convert its waiver to a SPA, anticipating that its family planning program would shrink after Medicaid expansion. Now, without a Medicaid expansion, many Virginians applying for health insurance at the Marketplace fall into the “coverage gap,” and are instead enrolled in the state’s family planning program. As a result, the state experienced a sharp increase in enrollment, although many beneficiaries are not using the coverage to secure family planning services, suggesting that they may be unsure of exactly what coverage they have (see further discussion below).
In states with Medicaid expansion, the ongoing role of family planning programs is more complex. In these states, many women who previously qualified only for a Medicaid family planning program are now able to secure full-scope Medicaid which provides them with a broad array of services that go well beyond family planning. Still, the vast majority of states expanding Medicaid that had family planning programs that predated the ACA have opted to maintain them. As California stakeholders explained, this is because family planning programs serve a unique role in helping women to secure high-quality family planning services, creating a natural focus on improving family planning services and for oversight and training. California’s family planning program is particularly essential for women who remain outside of comprehensive coverage due affordability issues. Even among women who have affordable, comprehensive coverage, they sometimes elect to use California’s family planning program because it is carefully designed to ensure confidentiality and privacy, even relative to a beneficiary’s spouse or parents.
One Medicaid expansion state in this analysis, Illinois, opted to drop its family planning program entirely. Many Illinois interviewees viewed this decision as appropriate given that, upon expanding Medicaid and establishing a Marketplace, low-income women became eligible for full-scope Medicaid or could enroll in Marketplace plans. Some Illinois providers and advocates, however, called for a re-examination of the decision. They cited their experience that some women are having difficulty securing family planning services, particularly for women with incomes above Medicaid thresholds, because they cannot afford Marketplace premiums.
Application, Eligibility and Enrollment
The ACA’s reforms to eligibility and enrollment procedures have changed how many women find out about and enroll in Medicaid (full-scope and family planning programs), creating both new opportunities and challenges. The ACA required states to adopt strategies to simplify the process of enrolling in Medicaid and Marketplace coverage including use of the “single, streamlined application.” These changes have many advantages for enrollees and states alike. Most importantly, the use of a single, streamlined application allows people to be evaluated for Medicaid, Marketplace coverage, and CHIP without requiring them to fill out and submit multiple, duplicative applications. At the same time, the “single, streamlined” application is actually significantly longer and more burdensome than states’ pre-ACA family planning applications, making it harder for people to apply specifically for family planning services and for family planning providers to assist with Medicaid applications. As stakeholders gain greater and greater familiarity with ACA eligibility and enrollment procedures, states, federal officials and advocates are looking for ways to have the best of both worlds – access to comprehensive coverage whenever possible but, for those who only qualify for family planning programs, a quick and efficient way to sign up.
Intersection with the Federally-facilitated Marketplace (FFM)
Nearly 70% of people in the country now live in states that rely on the Federally-facilitated Marketplace (FFM) and its eligibility and enrollment website, HealthCare.gov, as a primary vehicle for finding out about and enrolling in coverage.1,2 When an individual applies for coverage at HealthCare.gov and is determined ineligible for Marketplace coverage, the FFM also checks eligibility for Medicaid; however, the FFM is only able to review eligibility for major Medicaid eligibility categories – such as children, pregnant women and expansion adults. It is not yet able to determine eligibility for Medicaid family planning programs, a significant gap for women in states that have not yet expanded Medicaid.
Additionally, states that rely on the FFM have chosen whether the FFM can “assess” eligibility for Medicaid or “determine” eligibility for Medicaid. In states where the FFM “assesses” eligibility, the FFM transfers to the Medicaid agency all accounts that the FFM reviewed for Medicaid eligibility to enable the state to run its own eligibility determination processes. In doing so, the state can evaluate eligibility for all Medicaid categories, including for a family planning program. In states where the FFM “determines” eligibility, the FFM does not transfer accounts for anyone that the FFM “determined” ineligible for Medicaid.
This process creates particularly notable concern in the eight states that are “determination model” states – including Alabama.3 Alabama residents who apply for coverage at HealthCare.gov and are found ineligible for full-scope Medicaid are told they are ineligible for Medicaid by HealthCare.gov; they are not transferred to the Alabama Medicaid agency to allow the state to determine eligibility for and enroll them in the family planning program.4 Alabama interviewees expressed great concern about losing the opportunity to educate and enroll these individuals. In contrast, Virginia – an assessment state – receives accounts from the FFM for individuals who were found ineligible for full-scope Medicaid; the state then conducts its own processes to determine eligibility and may find the individual eligible for the family planning program.
Confusion About Coverage Status
Particularly in states that have not expanded Medicaid, interviewees highlighted that beneficiaries and providers are sometimes confused about the limited nature of the coverage available to family planning enrollees. Virginia, for example, a non-expansion state, has taken steps to ensure that low-income individuals who fall into the coverage gap are enrolled in the state’s Medicaid family planning program. With significant numbers of people stepping forward and seeking coverage through HealthCare.gov, this has resulted in family planning program enrollment in Virginia increasing from 8,000 in 2011 to 110,000 in 2016. The state, however, has not experienced a corollary increase in service utilization, suggesting that new enrollees may not be fully aware of how to use their limited coverage or may not be seeking family planning services. In response, the state has undertaken an effort to educate beneficiaries and providers about how to use the family planning program. It has created a family planning member identification card that is easily distinguishable from the card used for people with full-scope coverage, developed a separate Medicaid family planning handbook and will be conducting a survey and reviewing claims data to determine if member confusion has decreased.
Even prior to ACA implementation, Alabama found significant numbers of individuals were enrolled in the Medicaid family planning program but not utilizing services. The State now requires individuals to affirmatively request an eligibility determination for the family planning program by checking a specific box on the Medicaid application.5
Strategies to Increase Family Planning Enrollment
To address the challenges created by new eligibility and enrollment procedures, some states are relying on proven strategies that were in use prior to the ACA, such as on-site enrollment and presumptive eligibility. In California, for example, the state continues to allow applicants to enroll by completing a short application at their provider’s office to immediately secure coverage for their visit. California interviewees routinely praised the process for its success in helping women gain prompt access to family planning services, but also noted that the State continues to work to ensure providers assist applicants with enrolling in full coverage – rather than family planning-only. Similarly, Connecticut uses presumptive eligibility for its Medicaid family planning program, allowing women to be signed up for temporary coverage at their providers’ offices. In this instance, providers said that they view the presumptive eligibility policy as “crucial” to the success of the program, highlighting that people who are enrolled temporarily, begin taking advantage of their coverage, and find they are likely eligible for ongoing coverage are more motivated to complete the full application.6
Despite strong federal protections, interviewees in some states raised concerns about affordability challenges in Marketplace plans for low-income women in need of family planning services. Despite the availability of premium tax credits and cost-sharing subsidies for low- and moderate-income individuals in ACA Marketplaces, interviewees raised significant concerns about the affordability of Marketplace plans. In states with family planning programs, women who cannot afford Marketplace plans may still be able to directly secure family planning services through the family planning program.7 Given these issues, advocates and providers in Illinois would like the state to re-consider its decision to eliminate the state’s family planning program.
Even when women are able to purchase Marketplace plans, some interviewees raised concerns about ensuring access to family planning services. For example, Missouri advocates expressed concerned that Marketplace plans exclude many of the state’s family planning providers while some California interviewees reported that Marketplace plans often require prior authorization for LARCs. To address these issues, advocates and other interviewees are looking for increased oversight and monitoring of Marketplace plans’ compliance with family planning coverage and cost-sharing requirements. While state insurance departments may be the logical entity to provide this oversight, they have not traditionally served, or been asked to serve, this role and so may currently lack the staff and expertise to monitor how family planning benefits are provided.
Finally, there is heightened interest in dual enrollment in Marketplace plans and Medicaid family planning programs. If women can enroll in both, then the Medicaid family planning program may be able to assure continuity of care as well as offset any gaps in Marketplace plan coverage, such as narrow provider networks. While individuals are permitted to be concurrently enrolled in Medicaid family planning and Marketplace coverage in many states,8 this is not widely understood by beneficiaries, plans, or policymakers. Alabama officials, for example, reported they are actively working with the Centers for Medicare and Medicaid Services (CMS) to ensure that the FFM’s call center staff are aware that people may be enrolled in both forms of coverage and accurately inform callers of this possibility.
Stakeholders across the board reported that full-scope Medicaid and family planning programs generally cover the full range of family planning benefits that women are likely to require. “Family planning services” are defined broadly in federal law and guidance to include the full array of contraceptive devices and procedures (e.g., IUDs, birth control pills, condoms and other forms of over-the-counter methods), exams, counseling services, laboratory tests, and other services that women and their partners might need. Within these requirements, however, states have discretion to develop their family planning benefit packages, as well as to allow them to vary between full-scope Medicaid and a family planning program (e.g., in the selection of contraceptive options or in the number of cycles of contraception that can be dispensed at one time).9 In practice, though, interviews revealed that very minor differences exist, if any, between the benefits offered in family planning programs and full-scope Medicaid. While there have been some differences in the past, the states in this analysis have actively worked to eliminate them. California, for example, has fully aligned benefits in recent years by adding a broader range of contraceptive methods to full-scope Medicaid (e.g., the ring and patch) and allowing women to obtain up to 13 cycles of oral contraceptives in a single dispensation. In Virginia, where modest differences in family planning benefits between the family planning program and full-scope Medicaid still exist, the Department of Medical Assistance is working to align benefits between the programs.
On the other hand, there was variation across the six states in coverage of “family planning-related” services. States that choose to operate family planning programs are not required to cover “family planning-related” services. If they do, those services are reimbursed at regular Medicaid matching rates (while family planning services are matched at the enhanced 90% Medicaid matching rate). CMS has defined family planning-related services as “medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting.”10 Examples of family planning-related services include the treatment of sexually transmitted disease and infections (STIs) identified as the result of a family planning visit and complications arising from use of a birth control method. Preventive services routinely provided pursuant to a family planning service are also “related” services, including vaccinations to prevent cervical cancer.
|Text Box 1: Quality Family Planning Guidelines|
|In 2014, the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs (OPA) jointly released a set of recommendations addressing how family planning providers can deliver high-quality family planning services that help “women, men and couples achieve their desired number and spacing of children and increase the likelihood that those children are born healthy.” According to the report, family planning services should include:
The definition of comprehensive family planning services has moved beyond contraceptive methods to include screening and treatment for diseases that impact women’s and men’s ability and likelihood to conceive and the health of babies (see Text Box 1). Some states, like Virginia and Alabama, do not cover family planning-related services in their programs, which some interviewees pointed out limits women’s access to important services and may contribute to confusion about the role of the family planning program.11 States that do cover family planning-related services differ in what services they choose to cover.
For example, while all interviewee states cover the Human Papillomavirus (HPV) vaccine in full-scope Medicaid, only three states cover this service in their family planning program. Again, while all interviewee states cover colposcopies as a result of an abnormal pap smear, only three cover this service in their family planning program.12
Access to Family Planning Services
Interviewees suggested that women had access to services at a variety of provider sites that participate in family planning programs. Based on their experiences, most interviewees credited the well-established infrastructure of family planning programs, as well as the mission-oriented nature of many family planning providers. That said, interviewees across states varied significantly in where they believed that women usually received care. In Virginia, for example, interviewees reported that beneficiaries mostly receive services at private provider offices; in Alabama, more commonly through county-run public health agencies; and, in California, through a broad mix of public and private providers, with beneficiaries in some parts of the state relying heavily on traditional family planning clinics and federally qualified health centers (FQHCs). As discussed in more detail in the next section, however, data were notably lacking in most of the states on key access issues such as site of care, wait times, proximity of providers to beneficiaries, and use of the freedom of choice provision.
Medicaid Managed Care
In the midst of this generally positive portrait, interviewees raised a number of concerns about access, particularly in the context of Medicaid managed care. In managed care states, advocates reported that women who have switched from a family planning program into full-scope Medicaid, and therefore into a Medicaid MCO, often have more trouble securing family planning services through their MCO. In California, interviewees suggested that access issues arise because women are assigned to primary care providers they do not know or are far from their homes. More generally, they cited that MCO assignment algorithms do not take into account that the only provider many women of child-bearing age see is their OB/GYN, not a primary care provider. Interviewees were also concerned that MCOs sometimes impose step-therapy or other forms of utilization review inconsistent with state policy and federal regulations. Notably, Connecticut interviewees explained that the state discontinued its Medicaid managed care delivery system and moved back to direct state oversight in part because it was difficult to ensure that MCOs implemented the state’s policies as intended. Now, the Connecticut Medicaid agency can directly address any concerns providers or beneficiaries identify regarding barriers to accessing family planning services. Advocates and providers agreed it has become increasingly important to monitor how MCOs approach coverage of family planning services. Most of the states interviewed for this project had not yet reviewed their MCO contracts through a family planning specific lens (see Text Box 2 for an exception in Illinois). Those that have often do not yet have a plan for monitoring and enforcing unique provisions of importance to women and family planning providers (e.g., freedom of choice). Across different states, advocate and provider interviewees alike raised concerns about MCOs treating family planning services like other services – rather than as a preventive service — and imposing excess utilization review for LARC in particular. While state interviewees pointed to their authority for broad MCO oversight, as a practical matter, it was difficult to identify mechanisms, processes, or data that demonstrated how states could ensure on-the-ground compliance with protections like freedom of choice.
|Text Box 2: Illinois’s Approach to Oversight of Family Planning Services in a Managed Care Setting|
|Prior to terminating its family planning program in December 2014 and transitioning from fee-for-service to a managed care delivery system, Illinois implemented the “Family Planning Action Plan” (FPAP) as a means of ensuring that MCO contracts offer continuous access to high quality comprehensive family planning services. Through the FPAP, Illinois increased reimbursement rates and modified payment policies to encourage use of the most effective forms of contraception. The FPAP also requires that all Medicaid clients receive evidence-based counseling and have easy access to all methods of family planning without cost-sharing (co-pays/deductibles/co-insurance), step therapy failure requirements, or prior authorization.|
Freedom of Choice of Provider
Interviewees reported that the “freedom of choice” provision is not well understood by beneficiaries, family planning providers, and MCOs. This rule enables women to go to any Medicaid provider of their choice to secure family planning services (see Text Box 3). Beneficiaries often are not aware of the option and, in many instances, Medicaid MCOs have not yet established an appropriate infrastructure to implement it. As a result, interviewees reported instances when some beneficiaries who seek services from an out-of-network family planning provider were erroneously told they cannot see such providers. Providers also reported that when they do see patients who have gone out of network, they face major hurdles securing reimbursement from Medicaid. In some states interviewed for the analysis, providers could not even identify, despite trying, whether they should seek reimbursement from a beneficiary’s MCO or from the state. The new Medicaid managed care rule published in May 2016 seeks to address some of these issues, both by requiring appropriate access to family planning providers in-network (i.e., reducing the need for beneficiaries to use the freedom of choice provision) and by requiring plans to educate consumers about the provision.
Finally, fee-for-service states also raised some access issues. In Alabama, where most women in the family planning program are served through the state’s Department of Public Health Title X clinics, interviewees flagged that women may face long waits for appointments and may have to access some LARC-related services elsewhere because of state scope of practice laws.13,14 Alabama is not alone in having challenges in making the full range of contraceptive methods readily available to women. As noted in a later section on LARC, many providers struggle to have a stock of devices and trained staff who can conduct LARC procedures. Because of access challenges, a number of providers and advocates argued that maintaining specialized family planning clinics and providers is important because they allow for more focused, time-intensive counseling sessions, better provider training on family-planning specific issues like LARC insertion, and “all-in-one visit” provision of contraceptive services (lab work, stock of LARCs and other forms of contraceptives).
There is a need for more consistent, up-to-date, reliable and comprehensive data on Medicaid and family planning. While the states in this analysis could provide basic data on enrollment and expenditures in their family planning programs, they usually lacked a set of comprehensive data on Medicaid family planning, making it difficult to definitively draw conclusions on a range of questions, including service utilization by type, wait times, geographic proximity of providers to enrollees, appropriateness of care, ability to see the provider of an individual’s choosing, and the frequency with which people take advantage of the “freedom of choice” provision to see out-of-network providers.
While research has found that family planning waiver programs have resulted in increases in the share of women using contraception and declines in unintended pregnancy, there has been a dearth of data in recent years.15 One notable exception is California, which, until recently, has contracted with the University of California at San Francisco (UCSF) to conduct an ongoing evaluation of its Medicaid family planning program. Over the years, UCSF produced a series of evaluation materials, including an annual report on provider and client populations, services utilized, fiscal issues, and county-level characteristics, as well as analyses on whether women in need of family planning services are receiving them. These rigorous evaluations have documented the impact and reach of Medicaid funding for family planning in the state. For example, the most recent evaluation shows that the state’s Medi-Cal and Family PACT programs provided family planning services to nearly two-thirds (65%) of California’s low-women in need of publicly-funded contraceptives.16 In the spring of 2016, however, the state discontinued its contract with UCSF. The state now plans to conduct its evaluation activities in house. It is too early to assess the implications for the state’s ability to maintain its high standards for evaluation and monitoring, but several interviewees raised concerns, noting that major questions are arising about the implications of women transitioning from the family planning program to full-scope Medicaid (e.g., what is the effect on access and utilization? Use of LARC?).
An additional exception is the evaluation of Alabama’s family planning program, conducted by the University of Alabama at Birmingham. The evaluation, required because the family planning program is operated through a Medicaid 1115 waiver, addresses metrics associated with all of the State’s demonstration objectives (for example, “increase the portion of women eligible for [the family planning program] who actually enroll, and reduce race/ethnicity and geographic disparities in enrollment”) as well as other measures that allow ongoing monitoring of the program. As part of ongoing monitoring, the evaluation plan uses claims data and participant surveys to review issues such as reasons for not using family planning services, choice of birth control, services accessed during family planning visits and use of care coordination services.
|Text Box 3: Key Provisions of the Medicaid Managed Care Final Rule Related to Family Planning|
|On May 6, 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule seeking to modernize Medicaid managed regulations and align them with evolving Medicare and Marketplace requirements. The final rule includes a number of provisions related to family planning services and providers, including:
Provider and Delivery System Reform Implications
Implications for Providers
Family planning providers continue to face an uncertain future. Women’s shift to greater use of Medicaid MCOs and Marketplace plans has created administrative and cultural changes for family planning providers, who were accustomed to fee-for-service Medicaid, Title X and self-pay patients. This availability of managed care coverage combined with Medicaid expansion is shaping the systems where women receive family planning services—particularly by increasing access to private providers—putting downward pressure on patient volume for some family planning providers. This change is occurring at the same time as use of LARC and revisions to pap smear recommendations are also reducing the number of visits that women need to get their contraceptive care. Furthermore, in many states, these challenges are combined with calls to lower Medicaid spending growth and political pressures that some family planning providers, like Planned Parenthood face as a result of the larger abortion debate (see Text Box 4).
|Text Box 4: Missouri’s Transition to State-Funded Family Planning Program|
|In April 2016, the Missouri Legislature passed a fiscal year 2017 budget requiring that Medicaid funding for family planning services not be “expended to directly or indirectly subsidize abortion services or procedures or administrative functions and none of the funds…may be paid or granted to an organization that provides abortion services.”17 As a result, Missouri is required to transition its federally- and state-funded family planning demonstration to a program funded with State-only dollars because, to receive federal funding, the State would have to include all qualified providers in the program. Missouri’s Medicaid agency released a demonstration phase out plan for public comment that indicates the State-funded program, titled “Missouri Woman’s State-Funded Health Services Program,” effective as of March 30, 2017.18
These significant changes to the family planning program bring uncertainty to enrollees trying to access family planning services and to family planning providers. From 2011 to 2012, Texas took several actions to reduce funding to and then exclude Planned Parenthood affiliates from its family planning program, eventually replacing its Medicaid family planning demonstration with a state-only funded program. Analysis of these changes were associated with reductions in provision of LARC and increases the rate of childbirth covered by Medicaid.19 Other studies have found that maternal mortality is on the rise in Texas but have not conclusively identified the cause of their increase.20
As a result of these changes and challenges, many family planning providers interviewed for this report indicated that they are facing significant pressure to adjust their approach to providing care. Some are re-positioning themselves as providers of a broader array of services, including primary care and behavioral healthcare services. For example, family planning providers in California, Connecticut, and Virginia mentioned expansion into additional primary care services as a strategy to attract new patients, address unmet needs and better position themselves for longer-term sustainability.
Family planning providers are also starting to build stronger partnerships and referral relationships with other providers for needed services. For example, a Planned Parenthood affiliate in Virginia that expanded into primary care joined a safety net collaborative with FQHCs and free clinics, allowing it to tightly manage care while also referring out to specialists for needed services. In Connecticut, a Planned Parenthood affiliate hired staff to help women whose breast health issues were identified during a family planning visit connect with other providers who offer additional, specialized services (e.g., mammograms) and find insurance coverage if necessary.
Interviewees, however, also noted that not all family planning providers are interested in or able to adopt such changes. Many family planning providers either operate in rural markets that do not support service expansion or in urban markets with too many competing primary care providers, including FQHCs that long have been partners in meeting other primary care needs of the underserved population. Other providers would rather stick closer to core family planning services, and focus on increasing reimbursement and awareness of those services.
Many family planning providers reported putting new effort into contracting with Medicaid managed care and Marketplace plans. They said they found this work to be particularly challenging because they must develop contractual arrangements with each plan, rather than simply contracting with a single entity (the state agency). In Missouri, interviewees noted that only about 50% of family planning sites that receive Title X funds have experience with and are comfortable with contracting and negotiating with MCOs. Despite administrative challenges, many providers have sought this pathway in the hopes that successful contracting would raise reimbursement rates and offset declines in volume and stagnation of Title X funding. Additionally, contracting with Medicaid managed care entities is one way to “solve” the challenge of obtaining reimbursement for providing out-of-network services, as allowed under the freedom of choice requirement.
Providers continue to press Medicaid MCOs for higher reimbursement for family planning services. In California, providers report that reimbursement arrangements are lower in Medicaid managed care than they receive under fee for services through FamilyPACT, in the state’s family planning program. With significant numbers of women moving from the family planning program to full-scope Medicaid, they report that this has posed fiscal challenges for family planning providers. In other states, providers report that many Medicaid MCOs have a “take it or leave it” approach when they offer rates to family planning providers, attributing this to MCOs not accruing the benefits of preventing unintended pregnancies because of high churn in and out of MCOs.
Some public health family planning providers, such as county departments of public health, reported that they largely continue to operate “as usual,” experiencing little direct impact from the ACA. These providers are sustaining their family planning work with a combination of government grants, self-pay, foundation funding, and some Medicaid dollars. Although they have experimented with helping their clients find coverage, some interviewees reported that they had eased up on these efforts in recent years.
Role of Family Planning in Delivery System Reform
Many states are engaging in efforts to improve health outcomes and lower costs, spurred by State Innovation Model (SIM) grants, new opportunities for Medicaid waivers that can finance some of the cost of delivery system reform, and a steady drumbeat from the Center for Medicare and Medicaid Innovation on the imperative to reform the health care delivery system. These efforts will continue in light of final MCO regulations, which encourage states to implement alternative payment structures and provide states with enforcement mechanisms to ensure value-based MCO payment structures are enacted.
Interviewees, however, consistently report that family planning issues are not being addressed in discussions of Medicaid and delivery system reform. Among the six states reviewed for this paper, none had included family planning services in their reform efforts except in the context of maternity care (e.g., LARC insertion post-delivery). The exclusion of family planning providers from the larger debates over delivery system reform reflects the heavy focus on the most expensive enrollees and services, not the often younger and relatively healthy Medicaid beneficiaries who use family planning services. Many interviewees expressed concern that the exclusion of family planning services by MCOs and state agencies is a major missed opportunity, reflecting a lack of understanding that many women consider their family planning provider to be their primary source of care and feel more comfortable sharing information with them.
In making the case for their role in delivery system reform, provider interviewees explained that they are often the gateway into the healthcare system for low income and racially and ethnically diverse women of reproductive age. Their populations are generally healthy, but due to their socioeconomic status, are at greater risk of developing chronic illnesses and experiencing behavioral health and substance abuse issues, making it important that reform efforts include them. Additionally, they noted that research indicates that the government saves $7 for every $1 spent on family planning programs21 and that family planning providers can help Medicaid programs avoid the delivery costs associated with unintended pregnancies, as well as poorer maternal and infant outcomes associated with unplanned pregnancies or inadequate spacing between pregnancies.
As family planning providers begin to advocate more aggressively for inclusion in delivery system reform efforts, they are starting to produce some changes. For example, Connecticut has received a $45 million SIM grant from the federal government to transform how healthcare services are delivered in the State. Connecticut family planning providers have been tracking this initiative and actively participating in it by serving on governance committees that oversee the effort. One of Planned Parenthood’s affiliates in Connecticut has been invited to participate in the “Advanced Medical Home Vanguard Program” within the State’s SIM structure, allowing it to receive technical support to transform the practice, more effectively work with other members of the local health care community and, ultimately, potentially improve care and lower costs.
Other interviewees mentioned that the lack of family planning specific quality measures has also been a hurdle for inclusion of family planning services in delivery reform efforts, as current efforts strive to provide incentives to meet target quality measures as well as manage high-cost populations. Some quality metrics address reproductive health issues, such as chlamydia screening, STI/STD screening, and cervical cancer screening, but they fall short of measuring whether family planning services are being provided effectively. Recognizing the critical role that quality measures play, the federal government and states are pursuing the development of usable family planning metrics. The 2014 CDC/OPA guidelines on provision of high-quality family planning services includes a recommendation to measure the proportion of women using contraception, highly-effective methods of contraception, or LARC methods.22 In collaboration with the CDC and OPA, CMS’s Maternal and Infant Health Initiative23 aims to collect and report data on new developmental quality measures to increase the use of effective contraception in Medicaid and CHIP. In September 2015, CMS granted 13 states and one U.S. Territory $400,000 total over four years to support their efforts to collect this information, though states may also report voluntarily. The measures24,25 are presented in Text Box 5:
|Text Box 5: Quality Measures for Family Planning—2014 CDC and OPA Guidelines|
|The percentage of women ages 15–44 at risk of unintended pregnancy that:
Among women ages 15 through 44 who had a live birth, the percentage that:
These measures were reviewed and adopted by the National Quality Forum in Fall 2016. Approval and validation of the measures are important steps for family planning services and providers to be recognized in measurement programs and broader delivery reform efforts. For now, though, the nascent stage of quality measures for family planning services has exacerbated the challenge of integrating family planning services into larger delivery system reform efforts.
Long-Acting Reversible Contraception (LARC)
Long-acting reversible contraception (LARC) continues to garner significant attention from states. While condoms and oral contraceptives are the most common forms of birth control that women use, about one-third of women who have been sexually active in the past year and who use a contraceptive reported using a LARC.26 Recognizing their high effectiveness rates and potential to reduce unintended pregnancies (see Text Box 6), many of the states in this analysis are actively reviewing their Medicaid LARC policies to reduce access barriers, while also seeking to ensure women are presented with a range of options and not unduly pressured to select a LARC.
Interviewees noted that a significant barrier to accessing LARC is the shortage of providers trained to insert LARC methods, which has been documented by other studies. Family planning-specific providers (e.g., Title X grantees) typically have received specialized training and have experience with the range of LARC options, but of primary care practitioners nationwide, only 42% are comfortable inserting IUDs, and only 11% for implants.27 As interviewees in Illinois pointed out, some providers can be reluctant to complete training even when it is available and sometimes hold onto misconceptions about LARCs (e.g., the erroneous belief that women should use IUDs only after giving birth at least once). In response to these challenges, states such as California and Virginia have organized provider training and educational opportunities aimed at dispelling myths about LARC and increasing the number of providers trained to offer these methods.
A second major barrier to LARCs has been cost and some states in this analysis are seeking to address is the high upfront cost of LARC devices for providers. One aspect of high-quality family planning is the same day provision of contraceptive methods once they are selected by a woman, but the high costs of LARCs makes stocking these devices financially challenging for family planning providers. States typically reimburse providers upon LARC insertion, not when the device is purchased; therefore, providers must take on financial risk and cover the upfront cost of LARC devices in order to maintain an adequate supply. If a woman requests a LARC method but fails to return for insertion at a follow-up appointment, the provider must absorb the cost of the device unless it is used by another patient. Moreover, LARC devices are usually expensive— they can run up to $90028 per device–and so keeping them in stock is prohibitively expensive for many providers. To address the situation, Illinois, as CMS highlighted in an April 2016 Informational Bulletin, is piloting a new program with Bayer HealthCare and Teva Pharmaceuticals (both LARC manufacturers) to make selected LARCs available in physician offices without upfront physician costs.29
An additional barrier to accessing LARC is the low Medicaid reimbursement rates for procedures. In most of the six states in this analysis, provider and advocate interviewees maintained that reimbursement rates for LARC insertion is generally low. In Missouri, in particular, interviewees noted that some family planning providers have stopped offering LARC in recent years due to the reimbursement rates. Some states, including California and Illinois, are responding by increasing Medicaid reimbursement rates for LARC dispensing and insertion. Illinois, for example, implemented the “Family Planning Action Plan” in October 2014, which raised Medicaid reimbursement rates for LARC devices and insertion/removal.30
States are also working to address LARC within the scope of Medicaid maternity payments. States historically reimburse hospitals for a woman’s labor and delivery within a single prospective maternity payment. State interviewees were concerned that in an effort to lower costs, providers may be dis-incentivized from offering LARC to post-partum women if the cost is included within that bundled payment. To address this concern, some states have opted to reimburse for LARC outside of the maternity bundle. In July 2015, Illinois started allowing hospitals to receive a separate payment for LARC devices, and for non-employed hospital providers to bill separately for the insertion, making it more financially attractive for providers to insert LARC after delivery.31
Interviewees also raised concerns about insufficient patient education and counseling on LARC methods. With little or no reimbursement for contraceptive counseling, providers have no financial incentive to counsel individuals on their contraceptive options, including LARC. Advocates and provider interviewees, in particular, noted that increasing and optimizing reimbursement for contraceptive counseling should be a priority in light of the emerging range of contraceptive choices. In particular, interviewees noted that reimbursement for non-licensed, non-clinical counselors, such as certified contraceptive counselors, could be beneficial and is similar to what is currently in place in many states for other programs (e.g., tobacco cessation counseling).
Text Box 6: Washington University School of Medicine’s Contraceptive CHOICE Center
|The Contraceptive CHOICE Center at the Washington University School of Medicine received a Center for Medicare and Medicaid Innovation grant to develop and test a contraceptive provision model that targets women at the highest risk for unintended pregnancy. The Center used this grant to design a standardized approach to contraceptive choice counseling that removes inherent provider and patient bias regarding different contraceptive methods, and demonstrated that it ultimately reduced unintended pregnancies. When using the Center’s comprehensive counseling approach, counselors or staff members walk patients through all the different tiers of contraceptive options, starting with the most effective options (e.g., LARC). Researchers at the Center found that the use of contraceptive choice counseling increased patients’ satisfaction with their contraceptive method, increased the use of LARCs and reduced the rate of unintended pregnancies among their sample population.|
At the same time, a significant number of provider, state and advocacy interviewees highlighted the importance of adopting a nuanced, balanced approach when promoting LARC. They cited the long history of forced sterilization of low-income women, particularly women of color, and the controversy that erupted over coercive practices used in the 1990s to promote Norplant as reasons to act with sensitivity. While strongly supportive of LARC, they advocated for a balanced approach that provides women with the information and counseling that they need to make an informed decision and, if they freely opt for a LARC method, the opportunity to readily access it. One state explained that it has steered clear of actively promoting LARC insertion at delivery unless women have agreed to the procedure well in advance because of concerns that doing so would be reminiscent of earlier coercive practices.32
In the six years since passage of the ACA, Medicaid and its role in family planning has evolved significantly. The change of federal administration, however, may result in many changes to the ACA, to Medicaid, and to family planning services. We have seen in Medicaid expansion states many low-income women have moved from family planning programs to full-scope Medicaid. Although this brings enormous benefits to women who can now receive comprehensive care, it has increased the importance of ensuring that Medicaid managed care organizations are well equipped to address the family planning needs of low-income women. In recognition of this, CMS issued a series of guidance aimed at ensuring that states and Medicaid MCOs deliver family planning benefits in accordance with federal standards and newly strengthened requirements that plans inform beneficiaries of their freedom to choose their family planning provider. This federal guidance could be adapted by the future federal administration through regulatory actions.
In non-expansion states, Medicaid family planning programs are perhaps more important than ever, offering key benefits to many low-income women who remain uninsured because they fall into the coverage gap. Efforts to cap Medicaid through block grants or entitlement caps could result in more limited federal requirements and incentives to support these programs, especially if the 90% federal Medicaid match requirement is lifted. States would likely still have the option to operate the limited scope family planning programs, but with limited funding and without the enhanced match, they may choose to direct funds to other services.
Despite the strong consensus in the United States that it is cost-effective and important to reduce the rate of unintended pregnancies, family planning remains on the margins of delivery system reform conversations. With the exception of Connecticut, none of the states in this analysis had actively incorporated family planning services into their state-driven delivery system reform efforts. One promising development in this regard is the expanding body of work aimed at developing performance metrics to evaluate whether women are receiving high quality family planning services.
Perhaps the aspect of family planning that is garnering the most attention from federal and state officials is the issue of how best to promote access to LARC. A number of the states in this analysis had actively reviewed their policies to ensure that there were not inappropriate medical utilization requirements on use of LARCS and/or had launched initiatives to train more providers on LARC insertion. However, there still is a marked discrepancy between the policies that states have “on the books” and the reality of access to LARC, as reported by a number of advocates and family planning providers. Moreover, although the issue of how best to support providers in having LARCs in stock is well recognized, most states had not yet devised approaches to tackling it.
As the frontline providers of care for many low income women of all racial and ethnic backgrounds, many family planning providers are frustrated to find themselves excluded from delivery system reform conversations or struggling to contract with multiple MCOs to provide care to women who long have been their patients. Many are increasingly making the case to payers and policymakers who want to prevent unintended pregnancies about the value that they can offer, highlighting their deep experience and training to provide family planning services, including those that pose stumbling blocks for other primary care providers (e.g., contraceptive counseling, LARC insertion), the ability to offer same-day access to family planning services, and a unique understanding of what differentiates family planning services from other medical services.
This analysis highlighted the lack of data available to systematically assess the implications of the ACA for Medicaid and its role in providing family planning services. With so much at stake for low-income women, family planning providers and policymakers are eager to continue to reduce unintended pregnancy rates, it will be important to find ways to gather data in the future on what is working and where more needs to be done to ensure that women in Medicaid continue to have access to high-quality family planning services.
Finally, this study was conducted in the summer of 2016 before the election changed the outlook for the ACA and Medicaid. The Trump Administration has signaled its willingness to put more decisions about the program’s benefits, eligibility, and distribution of funds in the hands of state policymakers. As we see in this study, several states have used the 1115 waiver process to extend Medicaid coverage for family planning services to groups that have historically been ineligible for full scope Medicaid coverage. However, state and federal policymakers could potentially also apply the 1115 waiver to restrict the range of participating providers, covered services, and eligibility criteria.
This study shows that when states have choices in crafting family planning benefits under Medicaid, the results can vary widely. Moving forward, it will be important to continue to monitor the impact of Medicaid policy changes at the federal and state levels to assess the impact on access to family planning services for low-income women and men.Introduction Appendix