Medicaid

The Medicaid landscape is changing in the United States and several trends are particularly important in the context of contraceptive coverage. Thanks to the ACA, many states are expanding Medicaid eligibility to include previously ineligible adults of reproductive age who will now receive coverage of all FDA-approved contraceptive methods. Additionally, some states are establishing or extending Medicaid family planning “expansion programs” that serve as an important source of contraceptive coverage for many low-income individuals. Other states are unfortunately phasing these expansion programs out. Finally, states have dramatically increased their use of managed care delivery systems, which in some cases has impeded access to covered contraceptives, particularly LARC methods.

 

Medicaid coverage requirements for LARC methods

Since 1972, federal law has required that all state Medicaid programs cover family planning services and supplies without cost-sharing for enrolled individuals of reproductive age. However, states have some flexibility when defining the specific package of family planning services and supplies that are covered. States also have flexibility to impose utilization controls, such as prior authorization, that limit the availability of covered services and supplies. For these reasons, Medicaid family planning coverage varies by state. While most, if not all, states cover LARC methods in some form, it is possible that states may have differing policies with regard to specific methods or the conditions under which they are covered. Providers should consult their state’s Medicaid provider manual(s) for state-specific coverage details. Additionally, providers should monitor remittances from Medicaid to ensure that reimbursement and payment practices reflect the policies in the provider manual.

Medicaid laws and implementing policy principles call for the removal of LARC methods to be a covered Medicaid service. However, states have flexibility when determining payment policies (e.g. fee-for-service, bundled payments, global payments), which may, in effect, deny separate reimbursement for removal in some contexts. Some states have also been known to deny coverage of IUD removal absent a medical justification. Providers should consult their state Medicaid provider manual(s) for state-specific coverage details and for instructions about how to bill for LARC method removal when the services are covered.

If your state Medicaid program does not cover a particular LARC method or a related service such as removal, or if your state places inappropriate limits or restrictions on these services, please e-mail NHeLP at nhelp@healthlaw.org with “reproductive health” in the subject line.

 

Medicaid Alternative Benefit Plan coverage requirements for LARC methods

Since 2005, states have had the authority to enroll Medicaid enrollees, with some exceptions, in Alternative Benefit Plans (ABPs). The benefit packages in these ABPs mirror the benefits in certain specified commercial health plans. The ACA raised the significance of ABPs by designating them as the benefit packages offered to the majority of the ACA’s Medicaid expansion population. (See Medicaid eligibility.)

While all state Medicaid plans are required to cover family planning services and supplies without cost-sharing, federal regulations now additionally require Medicaid ABPs to cover all of the preventive services that most commercial insurance plans must cover under the ACA, including all FDA-approved contraceptive methods, without cost-sharing. This means that millions of newly eligible low-income women who enroll through the Medicaid expansion will receive coverage of all LARC methods, no matter how the state defines its family planning benefit for the rest of its Medicaid program. Additionally, as explained in the section on commercial plans, the ACA contraceptive coverage requirements include related follow-up and side effect management, and importantly, LARC method removal. A growing number of states, including Idaho, West Virginia, and Kentucky, also enroll groups of Medicaid-eligible individuals other than the Medicaid expansion population into ABPs, who will also benefit from these requirements.

 

Medicaid managed care plans

In its early years, Medicaid operated almost exclusively through a fee-for-service payment system in which providers were reimbursed directly by state Medicaid agencies for each service provided. Now, almost all state Medicaid agencies contract with managed care entities, including managed care organizations (MCOs), and nearly three quarters of Medicaid beneficiaries receive services through some type of managed care arrangement.

While most managed care arrangements require enrollees to obtain services from a specific network of providers, federal law protects access to covered reproductive health services by guaranteeing that Medicaid enrollees can seek covered family planning services from any Medicaid-participating provider. This protection is called “freedom of choice” and applies even when an enrollee of a managed care plan seeks family planning services out of network. Whether out-of-network providers should submit claims to the patient’s managed care plan or directly to the state or other entity depends on the arrangement specified in the managed care plan’s contract, and providers should consult their Medicaid provider manual(s) or state Medicaid agency for more information.

Some states “carve out” family planning services and supplies from contracts with MCOs that claim a religious objection. In these instances, the state Medicaid program must still ensure that enrollees have access to these benefits and will typically cover them directly through a fee-for-service billing system. However, some states may require a denial from the managed care plan before agreeing to pay the claim. Providers should consult their state’s Medicaid provider manual(s) or state Medicaid agency for more information.

In addition, Medicaid managed care plans are permitted to place “appropriate” limits on covered services for the purpose of utilization control, unless their contract with the state prevents them from doing so. Some plans have used this flexibility to impose prior authorization and step therapy requirements that limit access to covered LARC methods.

If you encounter a utilization control policy in a Medicaid managed care plan that prevents access to a covered LARC method, please notify NHeLP at nhelp@healthlaw.org and include “reproductive health” in the subject line.

 

Medicaid family planning expansion programs

States have the option to extend coverage of family planning and related services to individuals who are not otherwise eligible for Medicaid. These programs are a critical source of contraceptive coverage for low-income individuals, particularly in states that have yet to expand their Medicaid programs. Eligibility for these programs may vary from state to state. As in the traditional Medicaid program, states have some flexibility when defining the scope of covered family planning and related services, and coverage can vary. Providers should consult their state’s Medicaid provider manual(s) or state Medicaid agency for state-specific coverage details. Some state family planning expansion programs are implemented through a time-limited “waiver” and are set to expire sometime between 2015 and 2018. The Guttmacher Institute provides a regularly updated list of state family planning expansion programs, expiration dates (where applicable), and eligibility criteria.