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

Reversible Contraception

Key Finding: Prescription Contraceptives

All responding states provide coverage for most prescription contraceptive methods approved by the Food and Drug Administration (FDA). In addition, with few exceptions, most states aligned their coverage of prescription contraceptives across all of their Medicaid eligibility pathways. While most contraceptives are covered, a number of states apply utilization controls such as quantity limits on oral contraceptives and injectables.

The survey examined state coverage policies for multiple types of contraceptive devices and methods including, prescription and non-prescription methods, as well as reversible methods and sterilization procedures for women and men. Reversible methods include a wide range such as long-acting reversible contraceptives (LARCs) – intra-uterine devices (IUDs) and implants; oral contraceptives; injectables, emergency contraceptives; and various other products and devices available by prescription or over-the-counter (OTC).

Long-Acting Reversible Contraceptives (LARCs)

LARCs are highly effective for extended periods of time, ranging from three to 10 years depending on the specific type that a woman uses. In the United States, three types of LARCs are available: Hormonal and non-hormonal IUDs and implants. All states participating in the survey cover all LARC methods through all of their Medicaid programs offering family planning services (Table 3). The ACA requires coverage of these benefits in Medicaid expansion programs.

Table 3: State Coverage of LARCs
Contraceptive Device or Service	Traditional Medicaid (n = 41)	Family Planning Waiver or SPA (n = 23)	ACA Medicaid Expansion (n=25)	Apply Limitations or Restrictions
Copper IUD	41	23	Required	3
Hormonal IUD	41	23	Required	6
IUD Removal	41	23	Required	4*
Implant	41	23	Required	3
Implant Removal	41	23	Required	3*
* “Medical necessity” is included in the count of states with restriction or limitations for IUD and implant removal.

LARC Limitations or Restrictions

Only a few states noted utilization controls or restrictions for devices. Typically, restrictions apply to benefit frequency or for specific devices (Table 4). For device removal, “medical necessity” was treated as a limitation since it is not clear whether states consider the desire to become pregnant a medical necessity. This was the most common restriction noted for device removal.

For removal of an IUD, Alabama specified the following criteria: the recipient develops high blood pressure or other medical condition that would allow for a progestin only method; any nulliparous woman who has a spontaneous expulsion within six months of placement; Mirena IUD is removed to allow a pregnancy; surgical removal of an embedded IUD in an office or outpatient setting. Missouri noted that the specific CPT code for IUD removal is not covered, but providers are instructed to use an office visit code for reimbursement. In addition to limits on quantity, California noted that LARC devices are limited to clinic dispensing only.

Table 4: State Utilization Controls for LARCs
	IUD Device	IUD Removal	Implant Device	Implant Removal
Quantity/frequency limits	AL, CA, MI, MO		CA, MI, MO
Brand/type restrictions	AL, ME, OK
Coverage subject to certain medical conditions or “medical necessity”		AL, NY, OK, TN		NY, OK, TN
Removal covered to allow pregnancy		AL

LARCs Provided Immediately Post Labor and Delivery

Key Finding: LARC Reimbursement

States are experimenting with a variety of payment policies to facilitate postpartum LARC insertion. Approaches include separate payments for LARC device as well as clinician fee outside of the global fee. Several states continue to include either the device or the clinical fee within the global fee that is used to typically pay for maternity care.

States were asked how they reimburse providers for LARCs provided immediately after labor and delivery. This has been the source of considerable research, public health education, and policy activity in recent years in part because data that suggests birth spacing is an important component of healthy pregnancies and optimal birth outcomes.¹ LARCs are among the most effective forms of reversible contraception and research suggests that providing them during the postpartum period, either at the time of delivery or at the follow up visit can help lower the rate of unintended pregnancies.

Labor and delivery is typically reimbursed through a global fee that covers the costs of all maternity care, including labor and delivery services, and postpartum care. Many providers have reported that the global fee is not sufficient to cover the costs of providing a LARC postpartum at the time of delivery or at the follow up postpartum visit. The absence of a separate fee or an increase has been a disincentive for some providers. Among the 41 states responding to the survey, the reimbursement methodology for hospitals most frequently reported is a global fee for both the LARC device and insertion (17 states), followed by 10 states that include insertion in a global fee and reimburse hospitals separately for the device. Conversely, the most frequently reported methodology for reimbursing other providers was a separate fee for both the device and insertion (25 states). Table 5 illustrates summary data for reimbursement for LARC device and insertion post labor and delivery. Appendix Table A1 provides detail for each state response.

Three states indicated no specific hospital reimbursement for post labor/delivery LARCs. Arizona indicated that when the state implemented a hospital APR DRG² payment methodology, the fee associated with the labor and delivery for the hospital did not consider the inclusion of LARC, but it will be considered in the future. The District of Columbia noted it does not reimburse for immediate post- partum LARC, but the managed care plans do, and the reimbursement methodology varies across the three contracted health plans. North Carolina reported that many hospitals and physician offices have chosen not to place LARCs in the immediate postpartum period.

States were asked to identify and briefly describe any known policy or reimbursement barriers that inhibit the provision of LARCs immediately following labor and delivery. Several states that use a global fee to reimburse hospitals noted low utilization of postpartum LARC provision, whether the global fee was for the device, insertion or both. Several states reported plans to change their reimbursement methodology.

Colorado and Tennessee use the global maternity fee to reimburse hospitals for both the device and insertion. Colorado notes that postpartum LARCs are currently covered and available under normal labor and delivery reimbursement but also stated that the state is “looking to carve out payment from the global [labor and delivery] fee, but [are] still working on an appropriate process and CMS approval.” Tennessee plans to unbundle payments in 2016 to allow for separate reimbursement for postpartum LARCs “…in hopes of improving access for this contraceptive technology to Medicaid enrollees.”

Georgia reimburses hospitals for LARC insertion using a global fee and reimburses for the device separately, but notes that few LARCs have been purchased by hospitals to date for immediate postpartum insertion. The state intends to make system changes in 2016 that will allow separate reimbursement to hospitals for postpartum LARC insertion.

Texas included LARC device reimbursement within the hospital DRG but effective January 1, 2016 allows hospitals to receive reimbursement for the LARC device in addition to the DRG payment when the device is inserted immediately postpartum.

Other states reported issues with global payments for postpartum LARC procedures and devices: Massachusetts, which uses global payments, noted that providers would prefer a different reimbursement mechanism; Minnesota noted that they do not have a different DRG for LARC procedures/devices following a birth, as there is with sterilization procedures following a birth; Oregon reported that the DRG payment does not adequately cover the hospital cost so they are currently considering options to enhance the reimbursement amount; Washington changed its policy to allow separate reimbursement for a LARC device and enhanced reimbursement for LARC insertion added to the RVU-based fee.

Two states that use a global hospital reimbursement for both the device and LARC insertion, Michigan and Ohio, reported no barriers to utilization. Virginia, which also uses a global reimbursement methodology, described a four month pilot project implemented by one of its managed care plans that allowed for separate payment for the LARC device. However, there were no requests for immediate postpartum LARC insertions, so the pilot ended. The state noted “…it appears that a primary potential barrier of accessing this method of LARC is lack of provider and member education and training versus policy and reimbursement.”

Oral Contraceptives

Key Finding: Oral Contraceptives

All responding states cover daily use oral contraceptives (Combined, Progestin only, as well as Oral Extended and Continuous use) regardless of the eligibility pathway. Few states allow a 12-month supply for oral contraceptives; supply limits are the most common method to control utilization.

Oral contraceptives are the most commonly used form of reversible contraception among women in the United States. All states surveyed cover all forms of oral contraceptives in their traditional Medicaid program and their family planning waiver or SPA as applicable. The ACA requires states to cover oral contraceptives for adults in their Medicaid expansion programs (Table 6). The survey also asked states whether they provide coverage for 12 months’ supply of oral contraceptives. Eleven of the responding states indicated that they allow a 12-month supply of oral contraceptives to be dispensed, but typically with some restrictions (7 states). For example, California³ and Virginia noted that 12-month dispensing is restricted to clinics and on-site dispensing by medical providers. Pharmacies may not dispense a 12-month supply, with the exception of California’s family planning expansion program.

Limitations and Restrictions

Supply limits are the most common restriction reported for oral contraceptives, and limits are most usually tied to the dispensing provider, or program (Table 7). Seven states reported they restrict their supply to three months. Vermont requires prior authorization for non-preferred brands, along with a trial of a preferred brand. Mississippi and Vermont include oral contraceptives on the state’s Preferred Drug List (PDL), which means that coverage for these drugs is not subject to prior authorization. Appendix Table A2 provides state response detail around 12 month supply dispensing and utilization controls for oral contraceptives.

Other Prescription Contraceptives – Injectable, Diaphragm, Patch, Ring

Almost all of the responding states covered the remaining prescription contraceptives included in the survey across all available eligibility pathways. These methods include injectable contraceptives, the diaphragm, contraceptive patch, and vaginal ring. California and Maine indicated they do not cover the subcutaneous injectable, but California was in the process of adding coverage for this method.

Limitations and Restrictions

The most common utilization control noted by states for these contraceptive methods is limits on quantity or dose (Table 8). States that identified quantity and/or dose limits for one or more of the methods include: Alabama, Arkansas, California, Illinois, Michigan, and Missouri. Other restrictions pertain to the type of provider that can provide or dispense the contraceptive. California allows only clinics to dispense injectable contraceptives, but restricts dispensing of diaphragms to pharmacies. The place of service – either pharmacy or clinic – for the contraceptive patch and vaginal ring depends on the type of product dispensed. Michigan allows up to two diaphragms per year, but they must be dispensed from the same billing provider. States also reported other policies and program integrity measures. For example, in Texas the claim for the product must be accompanied by a family planning diagnosis code.

Table 8: Coverage and Utilization Controls for Other Contraceptive Methods
	Traditional Medicaid (n=41)	ACA Medicaid Expansion (n=25)	Family Planning Waiver or SPA (n=23)	Number of States with Utilization Controls
Injectable – intra-muscular	41	Required	23	Quantity/dose: 5 Place of service: 1 Other: 4
Injectable – subcutaneous	39	Required	22	Quantity/dose: 4 Other: 4
Diaphragm	41*	Required	23	Quantity/dose: 4 Place of Service: 2 Other: 1
Contraceptive Patch	41	Required	23	Quantity/dose: 4 Place of Service: 1 Other: 3
Vaginal Ring	41*	Required	23	Quantity/dose: 3 Place of Service: 1 Other: 2
* North Carolina covers diaphragm fitting only; Georgia covers the Vaginal Ring as a component of a family planning visit.

Emergency Contraceptives

In addition to coverage for Copper IUDs, which can be used as an emergency contraceptive, the survey asked states about their policies with respect to oral emergency contraceptives, including ella (ulipristal acetate) which is only available with a prescription, and Plan B products (levonorgestrel)⁴ which are available OTC without a prescription.

A few states provide unrestricted access to emergency contraception, or provide Plan B without a prescription: Maryland, Nebraska, Oregon, and Washington. Only three states reported that they do not cover either form of emergency contraceptive pills in any of their Medicaid programs – Alabama, Idaho, and South Carolina. Thirty-eight states cover ella, and 35 cover both Plan B products and ella emergency contraceptives in their traditional Medicaid programs. The ACA requires that Medicaid expansion programs cover emergency contraceptives, but only with a prescription under the ABP (Table 9). This means that these programs must always cover ella, but only are required to cover Plan B with a prescription.

For OTC Plan B emergency contraception, 21 of 25 states with an ACA Medicaid expansion population provide coverage through that pathway. Alabama, Idaho, Indiana, Kentucky, Mississippi, and South Carolina do not provide emergency OTC contraceptive coverage in any of the eligibility pathways available within the state. Minnesota does not provide the benefit in its ACA Medicaid expansion, but does provide it in the traditional Medicaid program and through the family planning SPA. Wyoming does not provide the benefit through its family planning waiver but does cover the benefit under traditional Medicaid.

Utilization Controls and Restrictions for Emergency Contraceptives

In the case of ella, which requires a provider prescription, fewer states apply utilization controls across states compared to Plan B OTC products (Table 10). Only seven states note any kind of utilization control for ella, with quantity limits the most prevalent limitation. The most common utilization restriction imposed by states, other than requiring a prescription for OTC products is quantity control (6 states). Two states restrict the place of dispensing to pharmacies and Washington allows pharmacists to dispense OTC emergency contraceptives directly to the client without prescription. Appendix Tables A3 and A4 include more detail on state responses to survey questions concerning how states cover of emergency contraception.

Seven states cover Plan B products but do not cover other methods of OTC contraceptives (Georgia, Maine, Missouri, North Carolina, Tennessee, Vermont, and West Virginia). Of the 41 responding states, most require prescriptions for OTC products (29 states), including Plan B (27 states).

Over-the-Counter (OTC) Contraceptives

Key Findings: OTC Contraceptives

There is more variation in coverage for over-the-counter contraceptive methods compared to prescription methods. A number of states also require prescriptions for these methods to be covered by Medicaid.

In addition to emergency contraceptive options discussed above, states were asked about their Medicaid coverage policies for male condoms, spermicide and sponges which are available over the counter to the public. Under the ACA, full scope Medicaid expansion pathways must cover prescription methods, but the requirement does not apply to over the counter methods. The survey found more variability between states and between eligibility groups for over-the-counter methods, compared to prescription methods.

Fewer than half of responding states (20 states), cover all three types of OTCs in all eligibility pathways available within the state. Ten states do not cover any of the three OTC products in any Medicaid program: Alabama, Georgia, Idaho, Kentucky, Maine, Missouri, North Carolina, Tennessee, Vermont and West Virginia. As illustrated in Table 11, male condoms and spermicide are covered in 27 of the 41 responding states and the sponge in 26 states. All three types of contraceptives were covered for ACA Medicaid expansion groups in 18 states of the 25 states with that eligibility pathway. Most of the responding states with a family planning waiver or SPA cover male condoms, spermicide and sponges (18, 17, and 17 states respectively). Appendix Tables A5 and A6 provide additional detail on state coverage of OTCs and utilization controls applied and coverage of OTC contraceptives in each of the eligibility pathways.

Utilization Controls for Over-the-Counter Contraceptive Supplies

Only six states noted no restrictions for any of the three OTC supplies for which they provide coverage: Illinois, Indiana,⁵ Maryland, Minnesota, Nebraska and Oregon (Table 12). Requiring a prescription is the most common utilization control for OTC contraceptive supplies. This is likely due, at least in part, to the established reimbursement mechanism to pharmacies for prescription drugs. Twenty-two states require a prescription or other form of documentation for OTCs. Michigan requires a prescription for spermicide and sponges purchased OTC, but does not require a prescription for condoms. Delaware also requires a prescription for both spermicide and sponge contraceptives, but does not cover male condoms.

Some states noted differences in coverage of OTCs based on whether the supply was obtained through a pharmacy benefit or through a clinic (point of service). For example, Virginia restricts access to all three OTC types to pharmacy dispensing only with a prescription. Connecticut does not cover spermicide under the retail pharmacy benefit (but does cover condoms that contain spermicide). Under the medical benefit, spermicide is covered when provided by an enrolled family planning clinic or from a medical/surgical supplier. Texas only allows reimbursement to family planning agencies for dispensing male condoms and spermicide. In Mississippi, condoms are only reimbursable through a medical claim for family planning waiver participants.

Table 12: Methods Used by States to Restrict Utilization of OTC Contraceptive Supplies
	Male Condom	Spermicide	Sponges
No restrictions (6)	IL, IN, MD, MN, NE, OR	IL, IN, MD, MN, NE, OR	IL, IN, MD, MN, NE, OR
Quantity/Claim limits (3)	CA, MI, OH	CA, OH	CA
Point of service restriction (4)	MS, TX, VA	CT, TX, VA	VA
Prescription or other documentation required (22)	AK, AZ, AR, CA, CO, CT, DC, HI, IA, MA, MT, NV, NH, NM, NY, OH, OK, SC, VA, WA, WY	AK, AZ, AR, CA, CT, DE, DC, HI, IA, MA, MI, MT, NV, NH, NM, NY, OH, OK, SC, VA, WA, WY	AK, AZ, CA, CO, DE, DC, HI, IA, MA, MI, MT, NV, NH, NM, NY, OH, OK, SC, VA, WA, WY
Prior authorization (1)	OH	OH
* Ohio requires prior authorization to exceed quantity limits (36/month for condoms;1/month spermicide)