Source: https://healthlaw.org/resource/q-a-medicaid-coverage-of-reproductive-health-services/
Timestamp: 2019-04-26 07:51:36+00:00

Document:
All States have Medicaid programs. To obtain federal funding, States must meet requirements set forth in the Medicaid Act and regulations.2 In addition, 26 states have received ?waivers? from the federal government that give them permission to disregard some of the Medicaid requirements and extend family planning benefits to people who would not otherwise qualify for Medicaid.
There is considerable variation from state-to-state in terms of covered populations and benefits. This Q&A answers some questions about the federal requirements for Medicaid coverage of reproductive health services.
I. What services does Medicaid cover?
A number of Medicaid laws address the scope of benefits. Significantly, the coverage rules for adults differ from those that apply to children and youth (those under age 21).
In 2006, the Medicaid Act was amended to give States the option to enroll Medicaid recipients into pre-existing health insurance plans (e.g. a private or commercial health insurance plans).10 States choosing this option can ignore Medicaid?s traditional rules governing coverage of mandatory and optional services. Notably, the population groups that can be affected by this option are limited in the federal law and include, for the most part, healthy children, working parents, and pregnant women with incomes exceeding 133% of the federal poverty level. States electing the option must continue to cover EPSDT for children and youth. To date, only a handful of states (e.g. Idaho, Kansas, Kentucky, Missouri, South Carolina, West Virginia, and Wisconsin) have chosen this option. And while it is conceivable that states could receive federal approval to provide insurance plans that do not include family planning or other reproductive health services, none of the programs approved to date contain such limits.
II. What family planning services and supplies are covered?
When Medicaid was enacted in 1965, it did not include family planning services and supplies among covered services. However, Congress amended the Act in 1972 to improve the availability of family planning services. First, Congress required States to cover ?family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State [Medicaid] plan and who desire such services and supplies.?11 Congress also took the unusual step of setting a uniform, national rate of federal funding, set at 90 percent of the cost of the service or supply.12 As a result of these changes, State Medicaid programs must cover family planning services and supplies; however, they are responsible for only 10 percent of their cost.
III. Who is eligible for coverage of family planning services and supplies?
Medicaid Act and include pregnant women, people who qualify because of a disability, caretakers, and minors who can be considered to be sexually active.24 Family planning services and supplies are optional services for ?medically needy? beneficiaries. The medically needy are individuals whose incomes or resources exceed the categorical eligibility limits and are covered at State option.25 And as noted above, some states have received ?waivers? from the federal government that allow them to provide family planning services to individuals who would not otherwise qualify for Medicaid. For example, Louisiana extends coverage to otherwise uninsured women (aged 19-44) with family incomes at or below 200% of the federal poverty level (compared to Medicaid?s mandatory requirement of 133%), and Missouri extends coverage to otherwise uninsured, postpartum women (aged 18-55) for up to one year (compared to Medicaid?s mandatory requirement of 60 days).
IV. What types of family planning providers can a person choose?
Medicaid beneficiaries can obtain family planning services and supplies from any Medicaid-participating provider.
This freedom of choice is maintained even if the individual is enrolled in a managed care plan, such as an HMO. 28 Medicaid beneficiaries have the right to choose any family planning provider who is participating in their HMO (even if that provider is not their assigned primary care provider) or any other family planning provider who is participating in the Medicaid program, even if that provider is not part of the beneficiary?s HMO. The person can obtain family planning services and supplies outside the HMO without a referral from the HMO.
V. What types of cost sharing can be used?
VI. Does Medicaid cover abortion services?
VII. Are there requirements for informed consent?
These provisions are important to protect women who may be pressured to use longlasting contraceptives, regardless of side-effects, or who are facing family caps in cash assistance programs. Yet, the refusal of some states to cover the removal of IUDs or implantable contraceptives when a woman decides she would like to come pregnant may have a coercive effect.
Medicaid coverage of reproductive health services is critical for low and limited income women. The coverage rules can be complex and, to complicate matters more, can change. The National Health Law Program will continue to provide information about Medicaid coverage of reproductive health services and is available to provide technical support with Medicaid issues that may arise.
1 See Henry J. Kaiser Family Found. & Guttmacher Inst., Medicaid?s Role in Family Planning (Oct.
(documenting trends in public spending, nationally and state-by-state).
2 See 42 U.S.C. § 1396a.
(laboratory and X-ray), 1396d(a)(5)(A) (physician).
women. See Mo. Rule 13 C.S.R. § 70-60.010.
health care precisely tailored to his or her particular needs.?).
7 See 42 U.S.C. § 1396a(a)(17); 42 C.F.R. § 440.230.
8 See. 42 U.S.C. §§ 1396d(a)(4)(B), 1396a(a)(10), 1396a(a)(43), 1396d(r).
family planning, pregnancy testing and prenatal care.? CMS, State Medicaid Manual § 5124.B.3.
10 See 42 U.S.C. § 1396u-7 (added by Deficit Reduction Act of 2005, Pub. L. No. 109-171, § 6044 (Feb.
6, 2006) (eff. Mar. 31, 2006).
services. Proposed regulations on the subject have never been finalized. See 39 Fed. Reg. 42,919 (Dec.
Appendix F to subpart 441 (required consent form).
(May 2007) (regarding AZ, CO, DE, MA, MO, PA, VA).
13 42 U.S.C. § 1396b(a)(5).
14 CMS, State Medicaid Manual § 4270B.
16 CMS, State Medicaid Manual § 4270B.1.-2.
17 See n. 12, supra.
of Childbearing Age at 4, App. B (Dec. 21, 2006).
19 CMS, State Medicaid Manual § 4270.
20 Unpublished research, National Health Law Program (August 2007).
on Evolving State Medicaid Policies for Covering Emergency Contraception (June 2007).
24 42 U.S.C. § 1396d(a)(4)(C), CMS, State Medicaid Manual § 4270.

References: V. 
 § 1396
 § 70
 § 1396
 § 440
 § 5124
 § 1396
 § 6044
 § 1396
 § 4270
 § 4270
 § 4270
 § 1396
 § 4270