Medicaid Family Planning Programs: Case Studies of Six States After ACA Implementation

Introduction
  1. Ranji U & Salganicoff A. State Medicaid Coverage of Family Planning Services: Summary of State Survey Findings. Kaiser Family Foundation. November 2009.

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  2. Sonfield A & Gold RB. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2010. Guttmacher Institute. March 2012.

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  3. Gold RB, Richards CL, Ranji U, & Salganicoff A. Medicaid’s Role in Family Planning. Kaiser Family Foundation and Guttmacher Institute. October 2007.

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  4. Ranji U & Salganicoff A. State Medicaid Coverage of Family Planning Services: Summary of State Survey Findings. Kaiser Family Foundation. November 2009.

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  5. Ranji U & Salganicoff A. State Medicaid Coverage of Family Planning Services: Summary of State Survey Findings. Kaiser Family Foundation. November 2009.

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  6. Gold RB. Back to Center Stage: ACA Decision Gives New Significance to Medicaid Family Planning Expansions. Guttmacher Institute. October 2012.

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  7. Guttmacher Institute. State Policies in Brief: Medicaid Family Planning Eligibility Expansions. As of March 2016.

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  8. Murphy S. Planned Parenthood to continue contracts with Oklahoma. Associated Press, Chicago Tribune. June 30, 2016.

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  9. Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services (HHS). HSHHHMedicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability. Published in the Federal Register on May 6, 2016.

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  10. CMS, HHS. Clarifying ‘Free Choice of Provider’ Requirement in Conjunction with State Authority to Take Actions against Medicaid Providers.” SMD #16-005. April 19, 2016.

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  11. CMS, HHS. State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception. CMCS Informational Bulletin. April 8, 2016.

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  12. CMS, HHS. Medicaid Family Planning Services and Supplies. SHO #16-008. June 14, 2016.

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  13. Consumer advocates were available in a limited number of case study states.

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  14. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. Kaiser Family Foundation. As of July 1, 2015. Accessed May 24, 2016.

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  15. Alabama’s waiver provides the authority to offer family planning related services; however, state interviewees reported that family planning related services are not covered.

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  16. Prior to termination, Illinois operated the “Illinois Healthy Women” family planning waiver for women ages 19-44 with incomes up to 200% FPL.

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Report
  1. State Health Facts. Total Number of Residents. Kaiser Family Foundation. 2014.

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  2. State Health Facts. State Health Insurance Marketplace Types, 2016. Kaiser Family Foundation.

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  3. States that utilize the Federally-facilitated Marketplace (or “HealthCare.gov”) must elect whether to have the FFM make assessments of Medicaid/CHIP eligibility and transfer the account to the Medicaid/CHIP agency for a final determination (“assessment model”) or whether to delegate the authority to make Medicaid/CHIP eligibility determinations to the FFM (“determination model”). The eight determination states are Alabama, Alaska, Arkansas, Montana, New Jersey, Tennessee, West Virginia, and Wyoming. Marketplace model selections can be found: https://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-and-the-marketplace/medicaid-chip-marketplace-interactions.html

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  4. In contrast, 29 states are “assessment model” states that allow the FFM to assess Medicaid eligibility for them, but, that then take the information that people provided to the FFM and use it to conduct the final Medicaid determination themselves. This allows them to apply state-specific eligibility rules and procedures, and, in the process, to evaluate people for eligibility for family planning programs.

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  5. Alabama’s Application for Health Coverage & Help Paying Costs. Question 7 on Page 2 of 11.

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  6. When California converted its family planning program from a waiver to a SPA, it leveraged the ACA’s state option to use eligibility standards and processes that were applied on or before January 1, 2007, thereby permitting the State to continue its use of enrollment into the family planning program on-site at providers’ offices based on attested information.

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  7. Depending on state-specific rules, applicants in waiver states may be deemed ineligible for a Medicaid family planning program if they have access to alternative coverage that includes family planning services.

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  8. People can still enroll in a Marketplace plan and receive a premium tax credit even if they also are enrolled in a Medicaid family planning program. This is because Medicaid family planning programs do not constitute minimum essential coverage, and so do not preclude someone from premium tax credit eligibility. However, in some states, including California, Medicaid family planning rules adopted under waivers limit the coverage to people who otherwise lack family planning benefits.

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  9. Ranji U, Bair Y, & Salganicoff A. Medicaid and Family Planning: Background and Implications of the ACA. Kaiser Family Foundation. February 2016.

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  10. CMS, HHS. Family Planning Services Option and New Benefit Rules for Benchmark Plans. SMDL #10-013. July 2, 2010.

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  11. Family planning-related services are those services administered along with a family planning service (e.g., contraceptive counseling). Some examples of family planning-related services include the treatment of STIs, physical exams conducted as part of an annual family planning visit, and preventive services (e.g., HPV vaccine).

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  12. Walls J, Gifford K, Ranji U, Salganicoff A, & Gomez I. Medicaid Coverage of Family Planning Services: Results from a State Survey. Health Management Associates and Kaiser Family Foundation. September 2016.

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  13. Alabama’s Department of Public Health Title X clinics are staffed primarily by nurse practitioners who, under state law, cannot insert or remove IUDs or implantable devices unless there is a physician on staff. For example, if a woman selects an IUD as her form of birth control, the clinic must refer her to an off-site provider for insertion.

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  14. Alabama Administrative Code, Chapter 560-X-14-.03(2).

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  15. Kearney M & Levine P. Reducing Unplanned Pregnancies through Medicaid Family Planning Services. Brookings Institute. July 2008.

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  16. Cross Reidel J & Thiel de Bocanegra H. Access to Publicly-Funded Family Planning Services by Women in Need, Fiscal Year 2009-10 to Fiscal Year 2012-13. Bixby Center for Global Reproductive Health, University of California. November 2015.

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  17. Missouri House Bill 2011, 98th General Assembly, 2016.

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  18. Missouri Department of Social Services. Public Notice of Suspension of Federal Expenditure Authority for Section 1115 Family Planning Demonstration. Accessed August 4, 2016.

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  19. Stevenson AJ, Flores-Vasquez IM, Allgeyer RL, Schenkkan P, & Potter JE. (2016). Effect of Removal of Planned Parenthood from the Texas Women’s Health Program. The New England Journal of Medicine. Vol. 374:853-860.

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  20. MacDorman M, Declerq E, Cabral H, & Morton C. (2016). Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstetrics and Gynecology. Vol. 128, No. 3, (447-455).

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  21. Frost J, Sonfield A, Zolna M & Finer L. (2014). Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program. The Milbank Quarterly. Vol. 92, No. 4, (667-720).

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  22. Gavin L, Moskosky S, Carter M, et al. (2014). Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR; 63.

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  23. Center for Medicaid and CHIP Services. CMCS Maternal and Infant Health Initiative: Improving Maternal and Infant Health Outcomes in Medicaid and CHIP. Accessed August 4, 2016.

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  24. Office of Population Affairs and Centers for Disease Control. Measure PCU: Use of Contraceptive Methods by Women Ages 15-44 (Developmental Measure). Accessed August 3, 2016.

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  25. Ibid.

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  26. Salganicoff A, Ranji U, Beamesderfer A & Kurani N. Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women’s Health Survey. Kaiser Family Foundation. May 2014.

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  27. Pace LE, Dolan BM, Tishler LW, Gooding HC, & Bartz D. (2015). Incorporating Long-acting Reversible Contraception Into Primary Care: A Training and Practice Innovation. Women's Health Issues; Vol. 26(2), pp.131-134.

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  28. Yoost J. (2014). Understanding Benefits and Addressing Misperceptions and Barriers to Intrauterine Device Access among Populations in the United States. Patient Preference and Adherence; 8, pp.947–957.

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  29. CMS, HHS. State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception. CMCS Informational Bulletin. April 8, 2016.

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  30. Illinois Department of Healthcare and Family Services. Illinois Family Planning Action Plan. October 2014.

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  31. CMS, HHS. State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception. CMCS Informational Bulletin. April 2016.

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  32. While the immediate post-partum period is a particularly favorable time to provide LARC methods due to the softened state of the cervix, there are ethical concerns about attempting to advise or counsel women on contraceptive methods during the time of delivery.

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Appendix
  1. Prior to termination, Illinois operated the “Illinois Healthy Women” family planning waiver for women ages 19-44 with incomes up to 200% FPL.

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  2. Alabama’s waiver provides the authority to offer family planning related services; however, state interviewees reported that family planning related services are not covered.

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  3. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  4. Medicaid.gov. Medicaid & CHIP In Alabama. State Profiles, Eligibility.

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  5. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  6. Eligibility levels for both men and women go up to 146% when the income disregard in the ACA is considered.

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  7. Alabama Medicaid. Provider List. Family Planning/ Plan First. As of May 13, 2016.

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  8. Health Resources and Services Administration. Data Warehouse. Map Tool. Accessed August 25, 2016.

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  9. CMS, HHS. State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception. CMCS Informational Bulletin. April 8, 2016.

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  10. Bronstein J. Evaluation of Plan First. Demonstration Year 14. UAB School of Public Health. March 2016.

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  11. Medicaid.gov. Medicaid & CHIP in California. State Profiles, Eligibility.

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  12. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  13. California Department of Health Care Services - Office of Family Planning. Family PACT Client Data, 2013-2015. August 2015. Accessed August 2, 2016.

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  14. Family PACT Homepage. California Department of HealthCare Services.

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  15. CMS, HHS. Maternal and Infant Health Initiative Grant Award Announcement. September 10, 2015.

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  16. Medicaid.gov. Medicaid & CHIP in Connecticut. State Profiles, Eligibility.

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  17. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  18. Medicaid.gov. Medicaid and CHIP in Illinois. State Profiles, Eligibility.

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  19. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  20. Illinois Department of Healthcare and Family Services. Provider Notice regarding Important Family Planning Policy Change and Payment Increases. October 10, 2014.

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  21. Illinois Department of Healthcare and Family Services. Our Medicaid Commitment to Family Planning. August 20, 2014.

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  22. Illinois Department of Healthcare and Family Services. Hospital Billing and Reimbursement for Immediate Postpartum Long Acting Reversible Contraceptives. June 30,2015.

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  23. CMS, HHS. State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception. CMCS Informational Bulletin. April 8, 2016.

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  24. Illinois House Bill 5576. 99th General Assembly.

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  25. Medicaid.gov. Medicaid & CHIP in Missouri. State Profiles, Eligibility.

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  26. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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  27. Data may not sum to 100% due to rounding.

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  28. Missouri House Bill 2011, 98th General Assembly, 2016.

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  29. Missouri Department of Social Services. Public Notice of Suspension of Federal Expenditure Authority for Section 1115 Family Planning Demonstration. Accessed August 4, 2016.

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  30. Missouri Department of Social Services. LARC Devices Inserted Post-Partum During an Inpatient Hospital Stay. Provider Bulletin. Accessed August 16, 2016.

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  31. Medicaid.gov. Medicaid & CHIP in Virginia. State Profiles, Eligibility.

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  32. State Health Facts. Share of Medicaid Population Covered under Different Delivery Systems. As of July 1, 2015. Kaiser Family Foundation. Accessed May 24, 2016.

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