Family planning

CMS provides new clarity for family planning under Medicaid

Family planning services and supplies have been part of the Medicaid program since its inception half a century ago. And over the past few decades, Medicaid has become the primary source of public funding for family planning in the United States, representing three-quarters of this financing at the last count. This should come as no surprise, given the demographics of the Medicaid-insured population: according to unpublished tables of US Census Bureau data, 20% of US women of childbearing age (15-44) are enrolled in Medicaid, of whom 47 % those living below the federal poverty level.

This spring, the Centers for Medicare and Medicaid Services (CMS) gave unprecedented attention to these issues, recognizing the importance of Medicaid in enabling low-income women to access the family planning care they need. Scanning new regulations governing the participation of private sector managed care plans in the Medicaid program and Three Additional rooms advice to state officials focusing exclusively on family planning together form the most comprehensive set of rules, principles and recommendations for states that CMS has offered on the subject.

Since 1972, federal law has required all state Medicaid programs to cover family planning services and supplies for all enrollees of childbearing age, without co-payments or other forms of patient out-of-pocket. Federal regulations expand on this requirement, stating that those enrolled in Medicaid must be “free from coercion or mental pressure and free to choose which method of family planning to use.”

Beyond these basic rules, however, states have traditionally had considerable leeway in deciding which family planning services and supplies would be covered by Medicaid. States have sometimes imposed, or allowed Medicaid managed care plans to impose, additional restrictions on enrollees’ choice of methods and services in the name of controlling utilization and costs.

This started to change with the Affordable Care Act (ACA). Individuals newly eligible for Medicaid under the ACA’s Medicaid expansion are enrolled in Alternative Benefit Plans (ABPs), which are designed to mirror private sector health plans and therefore must comply ACA’s requirement to cover a wide range of recommended preventative services at no charge. share. This includes contraceptive advice and services and all contraceptive methods for women (currently 18 of them) recognized by the Food and drug administration.

CMS has not required states to cover the same list of contraceptive methods for traditional Medicaid enrollees. But in a June 14 Letter to State Representativesthe agency recommended that states cover all contraceptive methods, including prescription and over-the-counter methods, arguing that “because not all forms of contraception are suitable for all recipients, in the absence of contraindications Indications, patient choice and effectiveness should be the primary factors used in choosing one method of contraception over another.

Moreover, both in the letter of June 14 and in the Regulation of Medicaid Managed Care Released April 25, CMS has made it clear that many common usage control techniques are inappropriate and should not be used when it comes to family planning care because they interfere with enrollees’ ability to choose a method without coercion or mental pressure. Specifically, the CMS:

  • reminded states and managed care plans that cost sharing is prohibited for family planning services and supplies, including contraceptive drugs and devices;
  • explicitly prohibits the use of so-called step therapy (requiring a patient to try one method and fail before trying the method of their choice);
  • prohibits states and plans from imposing policies that restrict method switching, such as denying reimbursement for removal of an intrauterine device or contraceptive implant;
  • severely restricts the use of prior authorization by specifying that patients should be free to choose a method based on criteria such as side effects, clinical efficacy, reversibility of the method and ease of use; and,
  • discourage practices that impose inappropriate quantity limits, such as covering only one IUD every five years, even if a previous IUD was expelled or removed for a planned pregnancy.

In addition, CMS reiterated and strengthened privacy protections for Medicaid enrollees, including the obligation of states, plans, and health care providers to respond to requests to communicate with the enrollee through other means. or to another place (for example, by e-mail rather than by paper mail to his home). Many routine communications to those enrolled in Medicaid and private insurance, especially those related to billing and reimbursement, can inadvertently breach patient confidentiality. Protections against this possibility are particularly important for sensitive services such as family planning care.

Strong protections for family planning coverage must be paired with easy access to qualified providers, and Medicaid has several key protections for this. Above all, for a long time federal law ensures that Medicaid enrollees have free choice of any qualified family planning provider, even if enrolled in a managed care plan that otherwise limits enrollees’ coverage to a network of providers. Registrants cannot be required to obtain a referral for family planning, whether the provider is in-network or out-of-network.

Recent CMS regulations and guidelines reinforce and clarify these protections. For example, the April 25 Managed Care Regulations set new standards to ensure the plans’ provider networks are large enough to meet the needs of enrollees. This includes specific standards for obstetrician-gynecologists and a requirement that plans demonstrate that they have enough family planning providers in their networks to ensure timely access to care. Network access is important, as the agency noted, because “using network providers makes it easier to pay claims, helps enrollees locate providers more easily, and improves coordination of care.” .

In addition, CMS has used its regulations and guidance to remind states and plans of other related obligations: states and plans are required to inform enrollees of their right to seek care from the planning provider family of their choice. They must reimburse providers in a timely manner, even when a registrant obtains family planning care outside the network. And states must ensure prompt access by Medicaid enrollees to all covered information and services, even when health care providers and managed care plans have religious or moral objections.

In perhaps its most publicized move, CMS released a April 19 letter state officials that federal law prohibits them from discriminating against family planning providers. The letter was a public rejection of recent attempts in many states to deny Medicaid Reimbursement to Planned Parenthood health centers and other providers that offer abortion services or are affiliated with an abortion provider. CMS clarified that attempts by states to bar Medicaid providers without legitimate evidence of wrongdoing would violate the right of Medicaid enrollees to freely choose qualified providers. It explicitly stated that enrollees cannot be denied access to a provider solely because they offer the “full range of legally authorized gynecological and obstetric care, including abortion services.” The federal courts agreed with CMS on this interpretation of federal law.

In addition to clarifying states’ obligations and managed care regimes, CMS has taken steps to encourage states to go beyond what is simply required of them. In particular, the agency has expressed interest in helping states and family planning providers remove barriers to Medicaid enrollees’ choice of long-acting reversible contraceptives (LARCs), namely intra-uterine devices. -uterines and contraceptive implants. LARC methods are many times more efficient than oral contraceptives or everyday condoms, and are extremely cost effective in the long run.

In 2014, CMS launched a Maternal and Child Health Initiative, which has made increased access to and use of effective methods of contraception one of its two main pathways to improving maternal and child health outcomes. As part of this initiative, CMS is working with other federal agencies and selected states to test several new quality measures on the use of effective contraceptive methods by people enrolled in Medicaid. The main measure tested concerns the use of a wide range of effective contraceptive methods. It aims to encourage providers to ask their patients about their pregnancy intentions and to counsel them on the full range of contraceptive options.

A secondary measure focuses exclusively on the use of LARC methods. It is intended to be used by states and plans as a measure of access, to help identify providers and sites that rarely or never offer LARCs, and then help them identify and remove barriers. As CMS itself notes, the LARC-specific measure would be inappropriate if used to incentivize providers, as it could lead to coercive practices that violate enrollees’ free choice of methods.

Building on this previous work, a Bulletin of April 8 of the Maternal and Infant Health Initiative and a section of the June 14 letter to state officials detailed several approaches to overcoming commonly reported barriers to making LARC methods available to Medicaid enrollees. For example, CMS highlighted state efforts to improve reimbursement for LARCs and other contraceptive methods to help providers offer the full range of choices. These efforts have included decoupling payment for LARCs from other labor and delivery services, and allowing providers to bill for both an office visit and device insertion on the same day. CMS also touted collaborations with pharmaceutical manufacturers to help with the upfront costs of stocking expensive devices. He even suggested that states could request special permission from CMS to purchase contraceptive supplies in advance for providers.

Taken together, these recent actions by CMS represent a significant and welcome change in agency direction and recognition of Medicaid’s responsibilities as the United States’ primary source of public funding for family planning services and supplies. .