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

Overview

Medicaid plays a major role financing family planning services for low-income women in the United States. Family planning services are “mandatory” benefits under Medicaid and must be provided to individuals of childbearing age free of cost-sharing. There is, however, no formal federal definition of “family planning,” which has given states considerable discretion to determine the specific services covered under this benefit. Furthermore, a state may establish different coverage requirements for Medicaid funded family planning services for different eligibility pathways. The Affordable Care Act (ACA) created a new Medicaid eligibility category which has federally-specified coverage requirements for aspects of family planning (contraceptives, screening services, and counseling), but these requirements do not apply to traditional Medicaid available prior to the ACA. This has magnified the potential for variations in coverage standards for different Medicaid eligibility pathways (e.g. traditional Medicaid available prior to the ACA, ACA Medicaid expansion, or Medicaid Family Planning Expansion program) within a state. The multiple pathways and coverage options make it difficult to assess coverage differences for family planning services both within and across states under fee-for-service.

This report presents findings from a state-level survey on states’ family planning benefits under Medicaid, as of July 2015. The survey queried states about their coverage policies under fee-for-service for the following family planning services: reversible contraceptives, sterilization services, fertility diagnosis and treatment, services related to family planning and sexual health such as cancer treatment and partner violence, and managed care policies. The survey identifies differences between states as well as within states between Medicaid eligibility pathways: traditional Medicaid (available pre-ACA), Medicaid expansion under the ACA, and family planning-only coverage through a state Medicaid waiver or State Plan Amendment (SPA). All 50 states and the District of Columbia were invited to respond to the survey, but data are presented for 40 states and the District of Columbia that provided responses (Figure 1). Throughout the report, DC is counted as a state, totaling 41 respondents.

Figure 1: State Medicaid Eligibility Pathways for Women

Figure 1: State Medicaid Eligibility Pathways for Women

Key Findings

Reversible Contraception

All responding states cover nearly all prescription contraceptive methods approved by the Food and Drug Administration under their fee-for-service programs, including IUDs and implants (Table 1).1 Coverage of over-the-counter contraceptives, particularly emergency contraception, showed more variation and utilization controls. Most states, but not all states, have aligned their coverage of prescription contraceptives across all of their Medicaid eligibility pathways.

  • Thirty-six out of 41 states covered all prescription methods in the survey under their traditional Medicaid pathway. Of the five states that did not cover all methods, two states did not cover one form of injectable and three of them did not cover ella, an emergency contraceptive pill.
  • While most contraceptives are covered, a number of states apply utilization controls such as quantity limits on oral contraceptives and injectables. Some states, however, have moved in the opposite direction, permitting clinics to dispense a 12-month supply of oral contraceptives.
  • Coverage of IUDs and implants is widespread and no states reported that they limited access to long-acting reversible contraceptives (LARCs) by requiring prior authorization, although some have utilization limits under fee-for-service, such as limiting coverage to certain brands.
  • States are considering and adopting a variety of payment policies to facilitate postpartum LARC While maternity services are typically paid for with a global fee that includes postpartum care, some states have developed a separate payment outside the global fee to compensate clinicians and hospitals for postpartum LARC insertions. Several states continue to include either the device or clinician fee in the maternity global fee, which can be a disincentive for providers to insert postpartum LARCs given the relatively higher costs of IUDs and lack of separate reimbursement for the insertion.
Table 1: Summary Findings on State Coverage of Contraceptive Methods in Traditional Medicaid Programs
Covers 20 forms of prescription contraceptives in Traditional Medicaid Program (36/41 states) AK, AR, AZ, CO, CT, DC, DE, GA, HI, IA, IL, IN, KY, MA, MD, MI, MN, MO, MS, MT, NC, NE, NH, NM, NV, NY, OH, OK, OR, TN, TX, VA, VT, WA, WV, WY

5 states that do not cover all methods:

CA, ME cover all methods except Injectable- subcutaneous

AL, ID, SC cover all methods except ella emergency contraceptive

Cover 3 forms of LARC in Traditional Medicaid Program (41/41states) AL, AK, AZ, AR, CA, CO, CT, DE, DC, GA, HI, ID, IL, IN, IA, KY, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, SC, TN, TX, VT, VA, WA, WV, WY
Covers 2 forms of Emergency Contraception in Traditional Medicaid Program (35/41 states) AK, AR, AZ, CA, CO, CT, DC, DE, GA, HI, IA, IL, MA, MD, ME, MI, MN, MO, MT, NC, NE, NH, NM, NV, NY, OH, OK, OR, TN, TX, VA, VT, WA, WV, WY
Covers 4 forms of OTC contraceptives Traditional Medicaid Program (22/41 states) AK, AZ, CA, DC, HI, IA, IL, MA, MD, MI, MN, MT, NE, NH, NM, NV, NY, OH, OK, VA, WA, WY
NOTES: Prescription contraceptive methods in this survey are: Copper IUD, Hormonal IUD, Implant, Injectable- intra-muscular, Injectable- subcutaneous, Diaphragm, Contraceptive Patch, Vaginal Ring, Oral Contraceptive Pills Combined, Oral Contraceptive Pills- Progestin Only, Oral Contraceptive Pills-Extended Use, ella Emergency Contraceptive Pills, Tubal Ligation- General, Tubal Ligation- Post Partum, Sterilization Implant, and Vasectomy. LARC methods in this survey are: Copper IUD, Hormonal IUD, and Implant. OTC contraceptive methods in this survey are: Male condom, spermicide, sponges and levonorgestrel emergency contraceptive pills.
  • Coverage for emergency contraception (EC) pills, particularly the over-the-counter (OTC) product (levonorgestrel, also known as Plan B), is not as uniform as for the prescription method (ulipristal acetate, also known as ella). While at least one form of EC pills is covered in traditional Medicaid programs in most states, the OTC option is covered in fewer states and subject to greater utilization controls, sometimes requiring a prescription. Three states report that they do not cover either type of EC pills. All states reported that they cover the copper IUD, which can be used as an EC, in all of their pathways.
  • Variation in coverage across the states was most notable for over-the-counter (OTC) contraceptives, including condoms and Plan B emergency contraception. Coverage for OTC supplies also varied across state Medicaid eligibility pathways, and a number of states require prescriptions for coverage, which creates an access barrier for products the FDA has deemed to be safe and effective for over-the-counter use.
Sterilization and Fertility Services

Most states cover sterilization services in their FFS program, but few pay for fertility services. Federal law specifies that 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.

  • Medicaid family planning expansion program do not always pay for sterilization services for women.
  • While all states reported they cover vasectomies under traditional Medicaid, not all cover the procedure in their family planning expansion programs or under their full scope Medicaid expansion programs.
  • Very few states cover diagnostic testing related to fertility, including laparoscopy for women and semen analysis for men.
  • Only one state covers fertility treatments for either women or men, but this is restricted to individuals who have infertility as a symptom of separate medical problem.
Family Planning-Related Services

The definition of high quality family planning encompasses a broad array of services including screening and treatment for cervical and breast cancers, interpersonal violence screening and prevention, and sexual health counseling. These family planning-related services, however, are less consistently covered by family planning expansion programs than contraceptives.

  • Although breast cancer screening is considered “optional” under traditional Medicaid, it is a required benefit in ACA Medicaid expansion programs. All responding states provided breast cancer screening services under these two full scope eligibility pathways. Few states, however, provide this benefit through their family planning waiver or SPA.
  • All states cover Pap screening for cervical cancer regardless of eligibility pathway, but follow-up tests for abnormal screening results are less likely to be covered in state family planning waivers or SPAs.
  • HPV vaccines for young adults are covered in all but one state, but the benefit is less likely to be covered through a family planning expansion program.
  • Contraceptive counseling and screening for intimate partner violence are covered by most states, but services are typically subject to restrictions and are not always covered for all eligibility pathways available within a state.
Managed Care Policies

The majority of states have capitated managed care contracts that include family planning services. Many of these states, however, do not address how utilization controls can be used in the context of family planning in their contracts. Some of the states noted that they contract with MCOs that include providers with religious objections to family planning in their networks, but not all of these states detailed referral processes to assure that women can get family planning care from other providers.

  • 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 with managed care organizations.
  • A handful of states reported that they do not claim the enhanced 90% federal match for family planning services provided through managed care organizations.
  • 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.

Conclusion

The analysis of state responses to this survey found that overall most states cover a broad range of prescription contraceptive methods in their full scope, traditional Medicaid programs and their full scope ACA Medicaid expansions, but finds more variation in coverage through the family planning expansion programs. Thirty-six of 41 surveyed states report that they cover all prescription contraceptives for women through their full scope programs. While states are not required to cover all methods under all pathways, most do. However, there is more variation between and within states for coverage of over-the-counter contraceptives, including condoms and Plan B emergency contraception pills. In some states that provide coverage, it is only with a prescription which can limit access to these safe and effective methods. Furthermore, over the years the family planning field has evolved to encompass other services beyond contraception that help women and men maintain and control their reproductive and sexual health. Medicaid coverage for prevention and management of breast and cervical cancers and screening for interpersonal violence is available in most states, but not as consistently as for contraceptives. These preventive services must be covered by new private insurance plans as a result of the ACA, but there is no requirement that they be covered under traditional Medicaid or under the family planning expansion programs.

Access to the full range of contraceptive methods as well as related family planning services has become a standard of comprehensive health care for women and men in their reproductive years.2 As enrollment in the Medicaid program continues to grow as a result of the ACA and state decisions to expand coverage for family planning services, policy choices defining coverage of services under Medicaid family planning will continue to be a significant force shaping access to sexual and reproductive health services for low-income women and men in years to come.

Acknowledgements

The authors express appreciation for the assistance of several individuals who assisted with the preparation, testing, and refinement of the survey instrument, including Yali Bair of Ursa Consulting, Amy Moy from the California Family Health Council, Tasmeen Weik of the federal Office of Population Affairs, Melanie Reece of Colorado’s Department of Health Care Policy and Financing, and Lisa DiLernia of Michigan’s Department of Health and Human Services.

We thank the following colleagues from Health Management Associates: Joan Henneberry for guidance and subject matter expertise; Dennis Roberts for database development and management; and Nicole McMahon for assistance with compiling the state data tables.

We also thank the Medicaid directors and staff in the 40 states and the District of Columbia who completed the survey on which this report is based.

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