Of the many open-to-interpretation objectives of the Patient Protection and Affordable Care Act (ACA), the family planning services that are part of “mandatory” benefits have been among the most difficult to pin down. That’s largely because individual states have some leeway in deciding which services should be included as mandatory. At the same time, the several tiers of Medicaid have added to the confusion about what is covered and what isn’t.

To find out what the family services inclusion trend has been among the states, the Kaiser Family Foundation asked the 50 states and the District of Columbia to share their policies on family planning service inclusion. Not everyone responded; but Kaiser did gather data from 41 of the 51 entities.

The survey found that, in general, there was “wide coverage” of basic family planning products and services, particularly “most prescription contraceptives.” However, when asked about emergency contraceptives and other less traditional family planning services, coverage was far more variable. And services that address spousal abuse were apparently not considered to be essential in some states.

“While virtually all states surveyed covered family planning-related services like contraceptive counseling, well women visits, and cervical and breast cancer screenings, fewer (35 out of 41) reported coverage for screenings for intimate partner violence,” the report said. “Only one state, Nebraska, covered fertility treatments for either women or men and this coverage was limited to infertility caused by medical issues.”

Because Medicaid plays a central role in providing coverage in an increasing number of states, the iterations of the program now in place contributed to the variation in coverage. For instance, states that still have “traditional,” pre-Medicaid expansion benefits plans tend to offer less coverage because they are not subject to the mandatory services conditions of Medicaid expansion plans, which were made possible by the ACA.

Survey findings

However, overall coverage was fairly good for core family planning services. Following are some of the key findings:

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.
Other states have taken the opposite approach, and allow clinics to dispense a 12-month supply of oral contraceptives.
Coverage of IUDs and implants is widespread; no states reported that they limited access to long-acting reversible contraceptives by requiring prior authorization, although some have use limits under fee-for-service, such as limiting coverage to certain brands.
Payment policies to facilitate postpartum long-acting reversible contraceptives are appearing in more states, and others report they are studying such policies. 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 long-acting reversible contraceptives insertions.
Several states continue to include either the device or clinician fee in the maternity global fee, often seen as a disincentive for providers to insert postpartum long-acting reversible contraceptives given the relatively higher costs of IUDs and lack of separate reimbursement for the insertion.
Variation in coverage across the states was most notable for over-the-counter 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 OTC use.

Coverage issues

Fertility services surfaced as an area of rather broad variation in coverage. Among the examples cited by Kaiser:

Medicaid family planning expansion program do not always pay for sterilization services for women.
All states cover vasectomies under traditional Medicaid, but 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.

The authors predicted that, as Medicaid services continue to expand through the states, more low-income individuals and families will have access to basic reproductive and other family planning and health services.

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,” the authors said. “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.”

Instant Insights /

Family planning coverage still dependent upon state policies

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