Medicaid Managed Care and the Provision of Family Planning Services
Since the 1990’s, managed care has had an increasingly significant role in the delivery of health care services to Medicaid beneficiaries. With the passage of the Affordable Care Act (ACA), more individuals qualified for Medicaid than ever before, and the majority of those beneficiaries are enrolled in managed care arrangements. Regardless of the outcome of efforts to repeal or replace the ACA or cap Medicaid spending, managed care is likely to remain the dominant care arrangement for Medicaid beneficiaries across the nation. With three quarters of women of reproductive age in Medicaid enrolled in care arrangements through managed care organizations (MCOs), the effective provision of family planning services is an essential element of needed care for women and is critical to reduce unintended pregnancies among this population. The findings presented in this report are based on information collected from both a national survey and focus groups of leaders from Medicaid MCOs across the country who represented a cross-section of plans in terms of geographic region and the number of enrolled Medicaid beneficiaries. They were asked to address a variety of topics related to the provision of family planning services to low-income women including billing and reimbursement, provider recruitment and network adequacy, scope of benefits, member education, provider training, quality measurement, and state policy constraints.
Plans rely on clinics, including Federally Qualified Health Centers (FQHCs) and family planning clinics, to provide a wide range of comprehensive health care, including family planning services, to their members. Plans did not report having problems developing an adequate network. In fact, they report that they contract with the majority of FQHCs in the area they serve. They maintained that the importance of these health centers derives from their ability to provide a broad suite of health services, including family planning care. In addition, these centers are already embedded in the enrollees’ communities; therefore, the plan may ensure access to care through the providers their members are most likely to seek out. Many also reported that they have contracts with free-standing family planning providers, like Planned Parenthood, to provide family planning services to their enrollees.
The types of contraceptives covered by plans closely follow state policies; and some plans have policies that offer contraceptive coverage options that exceed what is available under fee-for-service programs. Plans felt that enrollees were not always aware of these options. Most plans reported covering all forms of emergency contraception, including Plan B®, ella®, and the copper intrauterine device (IUD), ParaGard®. Although ella® is required to be covered for ACA Medicaid expansion populations, some plans reported challenges with coverage of the drug, attributed to problems with formularies. While there is evidence that providing women who use oral contraceptives with six to twelve cycles of pills reduces unintended pregnancy rates,1,2 most plans in the study only cover one or three months of oral contraceptives at one time. Only one plan reported covering a 12-month supply, even though plans have the leeway to cover more cycles of oral contraceptives than the state does under fee-for-service. Almost all plans reported requiring a prescription for over-the-counter (OTC) contraception, such as Plan B ® emergency contraceptive pills and male condoms, and some plans also covered spermicides, sponges, and female condoms, but noted that enrollees could pay out of pocket for these items if they did not pay at the pharmacy counter. Plans reported that requiring a prescription is the only way for them to track utilization and pay for claims directly, but noted that members may not be aware of the requirements for over-the-counter contraceptive coverage.
The expense of stocking of IUDs and implants remains key challenge in ensuring access to Long Acting Reversible Contraceptives (LARC), such as IUDs and implants. LARC devices are usually reimbursed after insertion, requiring providers to take on a significant financial risk to cover the high upfront stocking expenses of devices that can cost as much as $1,000. Plans recognized that limited availability of on-hand LARC devices is often due to the prohibitive expense of stocking. This barrier may limit a beneficiary’s ability to obtain one the same day she requests it, an element of high qualify family planning care according to the Centers for Disease Control and Prevention (CDC). Some health plans reported that they have negotiated with local pharmacies to stock IUDs in order to improve the availability of LARCs to their members.
Plans suggested that state payment and reimbursement methodologies that bundle pregnancy services act as a barrier to care, particularly in the provision of post-partum LARC. Plans reported they largely follow the payment methodologies set by their state Medicaid agency. While plans may reimburse providers above the fee-for-service rates determined by the state, most said they do not due to the administrative burden of reconfiguring their claims systems. This has become particularly salient when the state pays for prenatal and obstetrics care with a global fee or bundled payment, as it has important implications for access to post-partum LARC such as IUDs or implants which most states still include in the bundled rate for pregnancy care. They noted that hospitals have little incentive to provide expensive LARC devices to Medicaid beneficiaries if the plan does not pay them for the devices separately. In response, plans noted that some states have changed their policy to reimburse for LARC services separately, outside of the global fee for pregnancy. In addition, plans expressed concerns that bundling pregnancy care into one payment does not enable them to see details in the encounter data, limiting their plans ability to customize care and education for their members based on the care they access.
Frequent eligibility changes and churn among members can create a disincentive for plans to provide LARC to their enrollees. State-specific changes in eligibility among Medicaid enrollees depend on the expansion status of the state. In non-expansion states, pregnant women typically lose eligibility 60 days post-delivery. Therefore, plans in these states reported little financial incentive to promote expensive methods of LARC to prevent unintended pregnancy when the new mother will likely lose her Medicaid eligibility and, thus, the plan will likely not receive the expected cost savings from their use. In addition, frequent churning between plans, even in states that have expanded Medicaid, was raised as a disincentive for plans to provide long-acting forms of contraception to members that may soon be enrolled in another MCO.
Some plans expressed concern about the issue of coercion in the promotion of LARC to Medicaid populations. Medicaid populations have a history of being subjected to coercive practices surrounding sterilization and certain methods of contraception. With many states’ heightened interest in the promotion of LARC due to its effectiveness in preventing unintended pregnancies, plans were concerned about the perceived or actual coercion of Medicaid beneficiaries to adopt LARC methods. They wanted to ensure that beneficiaries had access to these methods, but did not want their members to feel coerced into making the choice. While there is awareness of the potential of problems, most plans did not report this as a major issue that they have encountered.
Plans identified provider training as crucial to the education of members and their access to the full-range of contraceptive care; however, they did not report the implementation of any programs to train providers in their network. Some of the barriers reported by plans regarding access to LARC included the lack of provider knowledge about the appropriate use of IUDs, especially for post-partum women and among minors or women who have not had children. There was also a reported lack of providers trained in the insertion and removal of LARC methods. Nonetheless, no participating plan reported having implemented a program to train providers in this area nor any attempts to partner with academic institutions or clinician professional associations to ensure that physicians, nurse practitioners, and nurse midwives are receiving this training.
Plans did not report any specific policies to assure that in-network faith-based providers with religious objections to contraception do not limit access to family planning and reproductive health services for Medicaid enrollees. Many plans contract with religious providers that have objections to contraception—even though family planning is a mandatory benefit under Medicaid. Plan members may not be aware of the restrictions placed on their care before seeing one of these providers or that they are able to go out of network to the participating family planning provider of their choice to get contraceptive services. Plans did not report any policies to identify providers with religious or conscience objections that would make it possible proactively to provide referrals for care that might be denied to members. Plans also did not have a consistent method to inform members of their rights to seek care elsewhere if a service is denied by their provider.
Plans reported that they do not measure or evaluate the quality of family planning services. While plans do collect data on the standard state and federally required Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the National Quality Forum (NQF) endorsed measures, these systems have few quality measures focused on family planning care. Plans do not report collecting internal data on family planning services, nor do they measure if their providers are offering the full-range of contraceptive care. NQF has recently endorsed a new contraceptive measure, so this policy may change in the future as plans adopt the new measure.
Over the past two decades, managed care has transformed the way Medicaid beneficiaries receive essential health care services such as family planning and reproductive health care. States and managed care plans play a central role in shaping access to quality family planning and reproductive health services for millions of low-income women across the nation. The findings of this study highlight the unique challenges that Medicaid plans face in assuring their members have access, and reveals areas where plans can work to strengthen their networks and policies to improve care. The Trump Administration has signaled their willingness to put more decisions about Medicaid benefits, eligibility, and financing in the hands of state policymakers, and this will likely have implications for how plans provide family planning services to their members and the types of clinics they can contract with as part of their provider network. Looking forward, the state and federal programmatic decisions will undoubtedly shape Medicaid plan choices regarding the scope of services, the network of participating providers, and the policies that Medicaid plans will use to provide low-income women with access to high quality family planning services.