New federal rules currently under development for Medicaid health plans run by private-sector managed care organizations (MCOs) could significantly improve enrollees’ health coverage and care, including provision of family planning services. A new analysis in the Guttmacher Policy Review argues that to achieve this goal, Medicaid’s protections for enrollees should be strengthened, monitored and enforced in several important areas: coverage and cost-sharing, confidentiality, choice of providers, and access to information and care.

Medicaid is the joint federal-state program that provides health coverage to almost 70 million low-income Americans. The program increasingly relies on private-sector MCOs to administer coverage, a trend that has accelerated under the Affordable Care Act (ACA).

“Family planning is a small part of Medicaid, but Medicaid is central to publicly funded family planning,” says Adam Sonfield, author of the new analysis. “That is why enhancing patient protections under Medicaid managed care matters so much. By addressing current gaps, the Obama administration would strengthen this vital program on which millions of women and couples rely for family planning services.”

  • Coverage and cost sharing. Despite long-standing protections, gaps exist in Medicaid’s coverage of family planning services. To correct this shortcoming, CMS should ensure that all Medicaid enrollees are covered for the full range of family planning methods and services. MCO contracts should specify that cost sharing is prohibited for family planning care and should ban restrictions such as inappropriate coverage limits and prior authorization requirements.
  • Patient confidentiality. Confidential access to family planning and other sensitive care is essential but difficult to maintain. Confidentiality is often breached inadvertently by MCOs, for instance through communications about services, billing and benefits. CMS should require states to establish, monitor and enforce MCO requirements regarding the treatment of confidential information. CMS should also provide states with greater clarity and technical assistance about interpreting federal confidentiality rules.
  • Access to providers. Medicaid’s protections to ensure enrollees’ ready access to qualified providers are not strong enough. That is why MCOs must be required to meet strong standards about the scope and adequacy of their provider networks, specifically including safety-net family planning providers. Enrollees should also be informed regularly that they have the explicit right to go outside of a plan network to obtain family planning services and supplies. And CMS should make clear that states and MCOs may not discriminate against providers, including those providing or referring for abortion care.
  • Religious exemptions. Medicaid rules aim to strike a balance between protecting patients’ access to information and care and respecting religious objections by plans and providers. Yet, it is not clear that these complex rules are actually working well for enrollees. CMS should therefore clarify and emphasize that it is states’ responsibility to ensure enrollees have access to the full range of covered sexual and reproductive health information, referrals, services and providers.

“It is essential that any new rules get these protections right for Medicaid enrollees and the safety-net providers who serve them,” says Sonfield. “And it is equally important that enrollees know about these protections, and that states and plans comply with them. Efforts to improve Medicaid must pay attention to the details that could meaningfully improve the provision of family planning care for millions of Americans.”

Full analysis: “Making Medicaid Managed Care Work for Family Planning Coverage and Services,” by Adam Sonfield