Medicaid Strategies to Promote Increased Access to Long-Acting Reversible Contraception (LARC)

Posted May 24, 2016 by Tamara Kramer; Karen VanLandeghem, MPH

NASHP and NICHQ Release Issue Brief on Opportunities for States to Increase LARC Access through Medicaid Payment Policy

Tamara Kramer
Tamara Kramer

Unplanned pregnancies can present a tremendous challenge for many women, healthcare payers and the community, and are associated with a number of negative health outcomes, such as delayed prenatal care and premature births. Efforts like the Centers for Medicare and Medicaid Services’ (CMS) recent guidance and the Collaborative Improvement & Innovation Network to Reduce Infant Mortality (IM CoIIN) have improved maternal and infant health outcomes, while also highlighting the $10 billion cost burden Medicaid expends on unplanned births.

To reduce and avoid unplanned pregnancies, states are turning to Medicaid to increase access to long-acting reversible contraception (LARC). LARC implants and devices are safe and effective options for women to avoid unplanned pregnancies. Studies show intrauterine devices (IUDs), the most common form of LARC, have a less than 1 percent failure rate with one year of typical use. Despite their effectiveness, LARC remains underutilized, with only 10 percent of women of reproductive age reporting use. Some of the most significant barriers to greater LARC use are the high upfront costs to stock these devices, which prevent providers from offering same-day LARC insertion, and inadequate reimbursement strategies for providers.

States are using several Medicaid payment strategies to improve women’s access to LARC. Some of the most noted efforts include policies that enable immediate, postpartum LARC insertion, and payment strategies that reduce the burden for doctors seeking to stock LARC devices in outpatient settings.

Research shows that immediate, postpartum insertion of LARC devices is both medically feasible as well as highly desirable for women interested in healthy birth spacing and/or preventing future unwanted pregnancies. Prior to 2012, the greatest barrier to immediate postpartum insertion was Medicaid policies that prevented doctors and hospitals for billing for devices and their insertion following labor and delivery--with most states using one bundled payment to cover expenses incurred by providers related to childbirth. Nineteen states have updated their policies over the past four years to allow separate reimbursements for devices and insertion, and another eight states are moving towards implementation.

For more information on the use of LARCs in preventing unplanned pregnancies, the current availability and education for women, barriers to prescribing LARC, and potential Medicaid reimbursement models to improve LARC access, you can review the latest NASHP/NICHQ issue brief, Strategies to Increase Access to Long-Acting Reversible Contraception (LARC) in Medicaid.

A number of states are also looking to tackle the issues of cost and access in outpatient settings. In Texas, Medicaid providers who obtain LARC through specialty pharmacies are able to return unused and unopened devices to the manufacturers’ third-party processors. Delaware recently launched a statewide initiative to stock provider offices with LARC devices, using funding from the state’s Department of Public Health and private foundations. Other state strategies include removing Medicaid’s prior authorization requirements, ensuring that reimbursement rates for LARC include payment for device reinsertion and removal, as well as updating administrative rules to enable same-day billing. These and other policy strategies are highlighted in a new issue brief developed by the National Academy for State Health Policy (NASHP) in partnership with the NICHQ.

As states continue to adopt payment policies that support increased LARC access, it will also be important to make sure there is an equal focus on women’s control over their reproductive rights. Concerns have been raised about what LARC may mean for women’s choices related to birth control. Unlike birth control pills, patches or rings, a women needs to visit a doctor to have LARC removed. Access and women’s ability to make decisions about their fertility will need to be balanced by states as they increase LARC availability and restructure payment incentives for providers.

Tamara Kramer, JD, is a Policy Associate, and Karen VanLandeghem, MPH, is a Senior Program Director, on the Child and Family Health Team at the National Academy for State Health Policy.


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