In the United States, 25 million adult women are insured by their state Medicaid program. Medicaid covers 60 percent of all births in the United States as per federal law, and states must cover all pregnancy-related services for pregnant women with incomes up to 133 percent of the federal poverty line. There are two Medicaid insurance payment models: a fee-for-service model, where the state pays for individual services, and a managed care model, where private insurers collect monthly payments for each Medicaid patient they insure. In the past 20 years, the number of beneficiaries in Medicaid managed care has surpassed the number of beneficiaries in fee-for-service. Thirty-seven states have greater than 50 percent of their Medicaid beneficiaries enrolled in a managed care plan. Both Medicaid managed care plans and fee-for-service beneficiaries are required to provide essential health benefits as stipulated by the Affordable Care Act. These essential health benefits include maternity and newborn care, specifically including care for pregnant and postpartum women. Given the guarantee of these essential health benefits, how are some Medicaid managed care plans allowed to limit providing family planning services which fall under the auspice of maternity care?
There are a variety of implicit and explicit barriers through which managed care organizations (MCO) limit coverage of family planning services. In California, New York, Texas and Oregon, the state contracts with MCOs that can claim a “liberty of conscience” exemption from providing key contraceptive and family planning services. Only California has an explicit referral process to redirect participants to a willing provider. Technically, a patient is allowed to go to any eligible Medicaid provider to receive family planning services under federal law. However, MCOs make it difficult for providers outside of an MCO’s provider network to receive reimbursement for providing family planning services. Furthermore, only 11 of the 31 states surveyed by the Kaiser Family Foundation report explicit regulating utilization control of family planning/contraceptive services in their MCO contracts. Many plans are still allowed to use tools such as prior authorization, step therapy (trying cheaper therapies before more expensive therapies) and others to limit service coverage. Since family planning services are broadly defined in statute, plans have broad discretion over what falls under their family planning services benefit. Furthermore, while MCOs are required to maintain a provider network necessary to meet the needs of their beneficiaries, a 2015 Office of Inspector General report found a systemic shortage of providers and inaccurate provider directories.
Some beneficiaries are unable to obtain care even if service coverage is approved. The lack of regulation on utilization control, substandard referral process, and inadequately monitored provider network is alarming given that it gives religiously-affiliated plans broad discretion to limit utilization while still appearing to cover the benefit itself. Given the increase in the number of patients covered by religiously-affiliated plans across the country, this is a salient issue to address.
These restrictions have harrowing consequences for reproductive health.
Religiously-affiliated hospitals, health systems and plans have ethical and religious directives written into their charters that explicitly prohibit the use of most reproductive health services that aren’t “natural.” For example, religiously-affiliated providers, hospitals and plans would deny coverage for contraceptives when treating an ectopic pregnancy, a condition which endangers a woman’s life; instead, favoring surgical treatment which is higher risk. Contraceptives are standard-of-care and the safest option for treating an ectopic pregnancy, however, when insurers deny coverage for contraceptives broadly, patients are forced to pursue a more dangerous surgery. Furthermore, patients may have to pay out of pocket for expensive contraceptive methods such as long-acting contraception (IUD, tubal ligation, etc.) sterilization, birth control, and the morning-after pill. This out-of-pocket payment is a high barrier for low-income women covered by Medicaid; they are unable to afford any form of cost-sharing and will often forgo treatment when facing financial barriers. Lastly, denominational hospitals and plans often refuse to cover or provide emergency contraception given to women who are survivors of rape, at risk of severe complications during their pregnancy or who are at an advanced maternal age. This goes against emergency contraception practice guidelines provided by ACOG and forces pregnant women to find alternative treatment options during a time of high health risk.
The growth of religiously-affiliated plans is dangerous given the current administration and the Supreme Court’s inclination to protect the religious freedom of corporations. The Trump administration is already attempting to end an Affordable Care Act mandate which requires employers to provide contraceptive coverage. What will prevent the administration or the court from setting a precedent that allows for more religious freedom (claims/exemptions) for Medicaid MCOs? A rule from the Department of Health and Human Services or a court case can end many processes designed to limit coverage gaps due to a religious exemption (mandating referral practices, provider network oversight, regulation of utilization control, etc.).
In this era, it is especially important to assert the religious freedoms of the individual over private, governmentally-funded organization to assert protections of the establishment clause. The existing Church Amendment (1973) already prevents hospitals that receive federal funds from being forced to provide abortions or sterilizations. If religiously-affiliated plans were to receive similar protections, it would limit the freedom of patients seeking family planning services further, forcing vulnerable patients to navigate a thorny landscape of religious exemptions to receive a medically necessary service. Local advocates in every state must assert that while individual providers are free to exempt themselves from providing contraceptive services given their own “liberty of conscience,” hospitals, health systems and plans must be held accountable to cover family planning services such that all beneficiaries have reasonable, accessible options when they need it. This requires improving state-level protections against implicit and explicit methods of limiting coverages to eliminate unreasonable coverage gaps in family planning services.
Ishaan Shah is a premedical student and can be reached on Twitter @ishaantshah.
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