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Medicaid Managed Care and the Provision of Family Planning Services

Overview

Since the 1990’s, managed care has had an more and more vital position in the supply of health care providers to Medicaid beneficiaries. With the passage of the Affordable Care Act (ACA), extra people certified for Medicaid than ever earlier than, and the majority of these beneficiaries are enrolled in managed care preparations. Regardless of the end result of efforts to repeal or exchange the ACA or cap Medicaid spending, managed care is more likely to stay the dominant care association for Medicaid beneficiaries throughout the nation. With three quarters of women of reproductive age in Medicaid enrolled in care preparations by way of managed care organizations (MCOs), the efficient provision of household planning providers is an important factor of wanted look after women and is crucial to scale back unintended pregnancies amongst this inhabitants. The findings introduced on this report are based mostly on info collected from each a nationwide survey and focus teams of leaders from Medicaid MCOs throughout the nation who represented a cross-section of plans in phrases of geographic area and the quantity of enrolled Medicaid beneficiaries. They have been requested to deal with a spread of subjects associated to the provision of household planning providers to low-income women together with billing and reimbursement, supplier recruitment and community adequacy, scope of advantages, member schooling, supplier coaching, high quality measurement, and state coverage constraints.

Key Findings

Plans depend on clinics, together with Federally Qualified Health Centers (FQHCs) and household planning clinics, to offer a variety of complete health care, together with household planning providers, to their members. Plans didn’t report having issues creating an satisfactory community. In reality, they report that they contract with the majority of FQHCs in the space they serve. They maintained that the significance of these health facilities derives from their capacity to offer a broad suite of health providers, together with household planning care. In addition, these facilities are already embedded in the enrollees’ communities; subsequently, the plan might guarantee entry to care via the suppliers their members are most probably to hunt out. Many additionally reported that they’ve contracts with free-standing household planning suppliers, like Planned Parenthood, to offer household planning providers to their enrollees.

The varieties of contraceptives coated by plans intently comply with state insurance policies; and some plans have insurance policies that provide contraceptive protection choices that exceed what is out there beneath fee-for-service packages. Plans felt that enrollees weren’t all the time conscious of these choices. Most plans reported overlaying all types of emergency contraception, together with Plan B®, ella®, and the copper intrauterine gadget (IUD), ParaGard®. Although ella® is required to be coated for ACA Medicaid enlargement populations, some plans reported challenges with protection of the drug, attributed to issues with formularies. While there’s proof that offering women who use oral contraceptives with six to 12 cycles of tablets reduces unintended being pregnant charges,, most plans in the research solely cowl one or three months of oral contraceptives at one time. Only one plan reported masking a 12-month provide, regardless that plans have the leeway to cowl extra cycles of oral contraceptives than the state does beneath fee-for-service. Almost all plans reported requiring a prescription for over-the-counter (OTC) contraception, reminiscent of Plan B ® emergency contraceptive drugs and male condoms, and some plans additionally coated spermicides, sponges, and feminine condoms, however famous that enrollees might pay out of pocket for these things if they didn’t pay at the pharmacy counter. Plans reported that requiring a prescription is the solely approach for them to trace utilization and pay for claims instantly, however famous that members is probably not conscious of the necessities for over-the-counter contraceptive protection.

The expense of stocking of IUDs and implants stays key problem in making certain entry to Long Acting Reversible Contraceptives (LARC), corresponding to IUDs and implants. LARC units are often reimbursed after insertion, requiring suppliers to tackle a big monetary danger to cowl the excessive upfront stocking bills of units that may value as a lot as $1,000. Plans acknowledged that restricted availability of on-hand LARC units is usually as a result of the prohibitive expense of stocking. This barrier might restrict a beneficiary’s means to acquire one the similar day she requests it, a component of excessive qualify household planning care in response to the Centers for Disease Control and Prevention (CDC). Some health plans reported that they’ve negotiated with native pharmacies to inventory IUDs with a purpose to enhance the availability of LARCs to their members.

Plans instructed that state cost and reimbursement methodologies that bundle being pregnant providers act as a barrier to care, notably in the provision of post-partum LARC. Plans reported they largely comply with the cost methodologies set by their state Medicaid company. While plans might reimburse suppliers above the fee-for-service charges decided by the state, most stated they don’t on account of the administrative burden of reconfiguring their claims techniques. This has grow to be notably salient when the state pays for prenatal and obstetrics care with a worldwide charge or bundled cost, because it has necessary implications for entry to post-partum LARC comparable to IUDs or implants which most states nonetheless embrace in the bundled price for being pregnant care. They famous that hospitals have little incentive to offer costly LARC units to Medicaid beneficiaries if the plan doesn’t pay them for the units individually. In response, plans famous that some states have modified their coverage to reimburse for LARC providers individually, outdoors of the international payment for being pregnant. In addition, plans expressed considerations that bundling being pregnant care into one cost doesn’t allow them to see particulars in the encounter knowledge, limiting their plans potential to customise care and schooling for his or her members based mostly on the care they entry.

Frequent eligibility modifications and churn amongst members can create a disincentive for plans to offer LARC to their enrollees. State-specific modifications in eligibility amongst Medicaid enrollees rely upon the enlargement standing of the state. In non-expansion states, pregnant women sometimes lose eligibility 60 days post-delivery. Therefore, plans in these states reported little monetary incentive to advertise costly strategies of LARC to stop unintended being pregnant when the new mom will doubtless lose her Medicaid eligibility and, thus, the plan will doubtless not obtain the anticipated value financial savings from their use. In addition, frequent churning between plans, even in states which have expanded Medicaid, was raised as a disincentive for plans to offer long-acting varieties of contraception to members which will quickly be enrolled in one other MCO.

Some plans expressed concern about the concern of coercion in the promotion of LARC to Medicaid populations. Medicaid populations have a historical past of being subjected to coercive practices surrounding sterilization and sure strategies of contraception. With many states’ heightened curiosity in the promotion of LARC as a result of its effectiveness in stopping unintended pregnancies, plans have been involved about the perceived or precise coercion of Medicaid beneficiaries to undertake LARC strategies. They needed to make sure that beneficiaries had entry to those strategies, however didn’t need their members to really feel coerced into making the selection. While there’s consciousness of the potential of issues, most plans didn’t report this as a serious difficulty that they’ve encountered.

Plans recognized supplier coaching as essential to the schooling of members and their entry to the full-range of contraceptive care; nevertheless, they didn’t report the implementation of any packages to coach suppliers of their community. Some of the limitations reported by plans relating to entry to LARC included the lack of supplier information about the applicable use of IUDs, particularly for post-partum women and amongst minors or women who haven’t had youngsters. There was additionally a reported lack of suppliers educated in the insertion and removing of LARC strategies. Nonetheless, no collaborating plan reported having carried out a program to coach suppliers on this space nor any makes an attempt to companion with educational establishments or clinician skilled associations to make sure that physicians, nurse practitioners, and nurse midwives are receiving this coaching.

Plans didn’t report any particular insurance policies to guarantee that in-network faith-based suppliers with spiritual objections to contraception don’t restrict entry to household planning and reproductive health providers for Medicaid enrollees. Many plans contract with spiritual suppliers which have objections to contraception—despite the fact that household planning is a compulsory profit beneath Medicaid. Plan members will not be conscious of the restrictions positioned on their care earlier than seeing one of these suppliers or that they’re able to exit of community to the collaborating household planning supplier of their option to get contraceptive providers. Plans didn’t report any insurance policies to determine suppliers with spiritual or conscience objections that might make it attainable proactively to offer referrals for care that may be denied to members. Plans additionally didn’t have a constant technique to tell members of their rights to hunt care elsewhere if a service is denied by their supplier.

Plans reported that they don’t measure or consider the high quality of household planning providers. While plans do acquire knowledge on the normal state and federally required Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the National Quality Forum (NQF) endorsed measures, these methods have few high quality measures targeted on household planning care. Plans don’t report amassing inner knowledge on household planning providers, nor do they measure if their suppliers are providing the full-range of contraceptive care. NQF has just lately endorsed a brand new contraceptive measure, so this coverage might change in the future as plans undertake the new measure.

Conclusion

Over the previous 20 years, managed care has reworked the method Medicaid beneficiaries obtain important health care providers comparable to household planning and reproductive health care. States and managed care plans play a central position in shaping entry to high quality household planning and reproductive health providers for tens of millions of low-income women throughout the nation. The findings of this research spotlight the distinctive challenges that Medicaid plans face in assuring their members have entry, and reveals areas the place plans can work to strengthen their networks and insurance policies to enhance care. The Trump Administration has signaled their willingness to place extra selections about Medicaid advantages, eligibility, and financing in the arms of state policymakers, and it will probably have implications for a way plans present household planning providers to their members and the varieties of clinics they will contract with as half of their supplier community. Looking ahead, the state and federal programmatic selections will undoubtedly form Medicaid plan decisions relating to the scope of providers, the community of collaborating suppliers, and the insurance policies that Medicaid plans will use to offer low-income women with entry to top quality household planning providers.

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