News Release

New Medicaid Managed Care Rules Include Vital Protections For Women Seeking Family Planning

Delayed by Bush Administration, Rules Face Uncertain Future

A major new federal regulation slated to go into effect last month, but whose implementation has been put on hold by the Bush administration, has important implications for the delivery and accessibility of family planning services and supplies in Medicaid managed care settings, according to a new analysis, "New Rules Issued to Govern Delivery of Family Planning Under Medicaid Managed Care," by Rachel Benson Gold, deputy director for policy analysis with The Alan Guttmacher Institute (AGI).

The analysis appears in the April 2001 issue of The Guttmacher Report on Public Policy and is adapted from a new Institute report, Medicaid Support for Family Planning in the Managed Care Era, by Gold and AGI senior vice president Cory L. Richards, which was supported by the Henry J. Kaiser Family Foundation.

 

It examines the components and future of the first uniform national standards for Medicaid managed care, embodied in the Balanced Budget Act of 1997, and a detailed implementing federal regulation developed during a two-year review process by the Health Care Financing Administration (HCFA). Finalized just before the end of the Clinton administration, the regulation was immediately subject to a moratorium by the Bush administration, postponing its April 19, 2001, implementation date for at least two months. Taken together, the statute and regulation offer the following provisions:

• Medicaid recipients have a legal right to all covered services, and plans are obligated to ensure their enrollees access to care.

• Enrollees have a right "to receive from their health care providers the full range of medical advice and counseling that is appropriate for their condition." Medicaid managed care plans may not interfere with the communication between a patient and a provider.

• While plans can refuse to pay for counseling and referral services to which they have a religious or moral objection, they must inform enrollees of that decision.

• Further, plans must tell enrollees where and how to obtain information about services that are covered by Medicaid in the state but are not covered by the plan.

• Enrollees retain the right to obtain family planning services and supplies from the provider of their choice, even if that provider is not affiliated with their plan, and they must be notified of this right. Further, they must be given direct access to providers of "women's health care" for services "unique to women."

• Enrollees have the right to be informed about the benefits covered by the plan and how to access covered services, as well as about any cost-sharing that is required. Plans must also give enrollees information about services that are covered by Medicaid in the state but are not covered by the plan. Furthermore, plans are required to tell enrollees about how and where to access these services, any cost-sharing imposed and how transportation is provided.

Specifically, the analysis examines the role of the joint federal-state Medicaid program in providing family planning to women in the United States. Family planning is one of the few health services that federal law mandates all state Medicaid programs to cover, creating a legal entitlement to "family planning services and supplies" for recipients, including sexually active teenagers. Low-income women and their dependents, the Medicaid population most likely to be in need of family planning, are also the most likely to be enrolled in managed care.

The analysis also outlines Medicaid's transition over the last two decades from a program that paid for care on a fee-for-service basis to one increasingly organized around managed care. This transition has been largely accomplished by individual states' obtaining waivers from HCFA in order to mandate enrollment of Medicaid clients in managed care plans. The result is a patchwork of varying federal requirements for Medicaid managed care programs nationwide. This situation changed, however, with the passage of the Balanced Budget Act, under which the federal government will no longer require that states obtain waivers, but instead imposes minimum requirements governing most state Medicaid managed care efforts. The 1997 act provided the basic principles, and HCFA developed a detailed implementing rule.

Given the moratorium imposed by President Bush and pending legislative proposals to overhaul Medicaid and allow greater state flexibility, Gold comments, "Clearly, the future of Medicaid will be a major topic on the public agenda in the coming months, with the new managed care regulation squarely in the middle of the fray."