Health Insurance Application for Extended Family Planning Benefits

An updated version of this written report was released on February 17, 2022 and can be found here.

Overview

Medicaid plays a major role financing family planning services for low-income women in the United States. Family unit planning services are "mandatory" benefits under Medicaid and must be provided to individuals of childbearing age free of toll-sharing. There is, yet, no formal federal definition of "family unit planning," which has given states considerable discretion to determine the specific services covered under this benefit. Furthermore, a state may found dissimilar coverage requirements for Medicaid funded family unit 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), merely these requirements do not utilize to traditional Medicaid available prior to the ACA. This has magnified the potential for variations in coverage standards for different Medicaid eligibility pathways (e.thousand. traditional Medicaid available prior to the ACA, ACA Medicaid expansion, or Medicaid Family Planning Expansion programme) inside a state. The multiple pathways and coverage options make information technology difficult to assess coverage differences for family planning services both within and across states nether fee-for-service.

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

Figure ane: State Medicaid Eligibility Pathways for Women

Central Findings

Reversible Contraception

All responding states cover nearly all prescription contraceptive methods approved by the Nutrient and Drug Administration nether their fee-for-service programs, including IUDs and implants (Tabular array 1).¹ Coverage of over-the-counter contraceptives, particularly emergency contraception, showed more variation and utilization controls. Most states, simply non all states, accept 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 nether their traditional Medicaid pathway. Of the five states that did not encompass all methods, 2 states did non comprehend one grade of injectable and three of them did not encompass 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, even so, have moved in the contrary management, permitting clinics to manipulate a 12-month supply of oral contraceptives.
• Coverage of IUDs and implants is widespread and no states reported that they limited access to long-interim reversible contraceptives (LARCs) by requiring prior authorization, although some accept utilization limits nether fee-for-service, such as limiting coverage to certain brands.
• States are because 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 college 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 xx forms of prescription contraceptives in Traditional Medicaid Program (36/41 states)	AK, AR, AZ, CO, CT, DC, DE, GA, How-do-you-do, 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 embrace all methods except Injectable- subcutaneous AL, ID, SC cover all methods except ella emergency contraceptive
Cover iii forms of LARC in Traditional Medicaid Plan (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 Programme (35/41 states)	AK, AR, AZ, CA, CO, CT, DC, DE, GA, How-do-you-do, 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 Plan (22/41 states)	AK, AZ, CA, DC, Hullo, 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- Full 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 safe, spermicide, sponges and levonorgestrel emergency contraceptive pills.

• Coverage for emergency contraception (EC) pills, particularly the over-the-counter (OTC) product (levonorgestrel, also known equally Plan B), is not every bit uniform every bit for the prescription method (ulipristal acetate, besides known as ella). While at to the lowest degree i form of EC pills is covered in traditional Medicaid programs in most states, the OTC selection is covered in fewer states and subject to greater utilization controls, sometimes requiring a prescription. 3 states written report that they exercise non comprehend either type of EC pills. All states reported that they comprehend the copper IUD, which can be used equally an EC, in all of their pathways.
• Variation in coverage across u.s. was most notable for over-the-counter (OTC) contraceptives, including condoms and Plan B emergency contraception. Coverage for OTC supplies besides varied across state Medicaid eligibility pathways, and a number of states require prescriptions for coverage, which creates an access bulwark for products the FDA has accounted to be prophylactic and constructive for over-the-counter employ.

Sterilization and Fertility Services

Nigh 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 likewise.

• Medicaid family unit planning expansion program do not always pay for sterilization services for women.
• While all states reported they cover vasectomies nether traditional Medicaid, non all cover the process in their family planning expansion programs or under their full scope Medicaid expansion programs.
• Very few states embrace diagnostic testing related to fertility, including laparoscopy for women and semen analysis for men.
• Just ane state covers fertility treatments for either women or men, but this is restricted to individuals who have infertility equally a symptom of separate medical problem.

Family unit Planning-Related Services

The definition of high quality family planning encompasses a wide array of services including screening and treatment for cervical and chest cancers, interpersonal violence screening and prevention, and sexual wellness counseling. These family planning-related services, however, are less consistently covered past family unit 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 chest cancer screening services under these two full telescopic eligibility pathways. Few states, yet, provide this benefit through their family planning waiver or SPA.
• All states embrace Pap screening for cervical cancer regardless of eligibility pathway, but follow-up tests for abnormal screening results are less likely to exist covered in state family planning waivers or SPAs.
• HPV vaccines for young adults are covered in all only one country, 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 past most states, but services are typically subject to restrictions and are non ever covered for all eligibility pathways available inside a land.

Managed Care Policies

The majority of states have capitated managed care contracts that include family unit planning services. Many of these states, however, do not accost how utilization controls can be used in the context of family unit 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 unit planning in the capitation rate. Only 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 lucifer for family unit planning services provided through managed care organizations.
• California and New York, states with the nigh beneficiaries, also contract with organized religion-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 land responses to this survey institute that overall most states cover a wide 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 study that they cover all prescription contraceptives for women through their total scope programs. While states are not required to encompass all methods nether all pathways, almost do. All the same, there is more variation betwixt 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 but with a prescription which tin limit admission 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, merely not as consistently as for contraceptives. These preventive services must be covered past new private insurance plans as a result of the ACA, but there is no requirement that they exist covered under traditional Medicaid or under the family planning expansion programs.

Admission to the full range of contraceptive methods besides 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 consequence of the ACA and state decisions to expand coverage for family planning services, policy choices defining coverage of services under Medicaid family unit planning volition continue to be a meaning force shaping access to sexual and reproductive health services for depression-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 musical instrument, including Yali Bair of Ursa Consulting, Amy Moy from the California Family Health Quango, Tasmeen Weik of the federal Office of Population Affairs, Melanie Reece of Colorado's Section of Health Care Policy and Financing, and Lisa DiLernia of Michigan'south Department of Health and Human being Services.

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

Nosotros as well give thanks the Medicaid directors and staff in the xl states and the Commune of Columbia who completed the survey on which this report is based.

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Source: https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planning-benefits-results-from-a-state-survey/

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