Medicaid Sterilization Consent Forms: Variation in Rejection and Payment Consequences

Objective In 1974, the federal Sterilization Consent Form (SCF) was created for those with publicly funded insurance to document appropriate informed consent by a clinician for sterilization procedures. This form must be signed by the clinician and patient at least 30 days before the procedure and expires 180 days after being signed.1 While there are numerous barriers to desired sterilization, the Medicaid consent process is a major cause of unfulfilled sterilization requests.2 As long as they comply with federal statutes, states may modify the Medicaid SCF, further complicating this process.3 However, data regarding this state-level variability is largely unavailable.4 Federal policy dictates that the global obstetrical fee should not be affected by SCF rejection.5 We sought to describe how individual state Medicaid policies differed in terms of what constitutes proper SCF completion and the payment ramifications of a rejected SCF. Study Design A 25-question survey was administered with Qualtrics XM® to 50 United States state Medicaid Directors or the most appropriate state official based on a review of the state website. The survey assessed state officials’ knowledge of criteria used to assess completion and validity of SCFs, SCF rejection rate, and payment ramifications for rejected SCFs. Data were collected from January to May 2020. Deidentified data were analyzed and reported in aggregate. This study was given Exempt Status by the Tufts Health Sciences Institutional Review Board. Results There were 41 responses from 36 states for a 72% participation rate. Four states had submitted multiple nonidentical responses. Criteria for SCF rejection included an incomplete form (35, 85%), mismatching or incorrect dates/times on the SCF (28, 68%), and that greater than 180 days had passed since the patient’s signature rendering the form expired (27, 66%) (Figure 1A). Ten respondents (24%) estimated a SCF rejection rate of less than or equal to 10% while four respondents (10%) indicated a greater than 30% rejection rate (Figure 1B). The majority of respondents indicated that the ramification of a rejected SCF included the loss of payment for the postpartum sterilization procedure for the provider (32, 78%) as well as facility (29, 71%). Five respondents stated that a rejected SCF resulted in loss of the entire obstetrical global payment for provider and facility (5, 12% provider; 5, 12% facility). Conclusion From our survey, it is clear that wide variation exists between states or within individual states, in the criteria used by state Medicaid offices to assess SCF completion, rate of rejections, and subsequent payment ramifications for providers and facilities. While the majority of respondents identified objective measures (e.g. incorrect dates) as major reasons to reject SCFs, many also used subjective reasons (e.g. signature legibility). Though federal policy dictates that the global fee should not be affected by SCF rejection, our study found 12% of respondents indicated a loss of the global fee.4 The fear of payment loss can be a significant barrier to desired sterilization. Ensuring greater transparency and consistency in the Title XIX sterilization consent process within and between states is a key step to ensuring equitable access to postpartum sterilization.