Health Insurance Reimbursements Typically Do Not Cover Title X Providers’ Full Cost of Care

New Findings Underscore Need for Higher Reimbursement Rates, Show Enduring Importance of Title X and Other Grant Programs

Health insurance reimbursements received by safety-net family planning providers supported by the Title X program typically fall significantly short of what is needed to cover the actual cost of care provided, according to a new Guttmacher Institute study. Medicaid managed care plans generally reimburse for a lower proportion of costs than fee-for-service Medicaid, while private health plans generally reimburse for the highest proportion.

The analysis includes data from 43 respondents that operate Title X programs, representing services provided at 350 health centers to more than 900,000 contraceptive clients in 2010. The authors caution that the findings are not nationally representative.

"Overall, this study helps to quantify what Title X–supported family planning providers have long thought true—that reimbursement rates for both public and private insurance are not adequate," says Adam Sonfield, lead author of the study. "This issue has only become more acute as more clients at these centers have public and private insurance thanks to the Affordable Care Act."

Among the study’s key findings:

  • For patient visits, the median Medicaid fee-for-service rates were 45–49% of the actual cost of providing that care. Medians for insertion and removal of long-acting reversible contraceptive (LARC) methods, like the IUD or contraceptive implant, were somewhat higher (49–74%).
  • Reimbursement under Medicaid managed care was typically lower than under Medicaid fee-for-service. Medicaid plans paid a median of 41–46% of actual costs for patient visits and 27–33% of costs for IUD insertion and removal.
  • Private insurance reimbursement was typically slightly higher than Medicaid fee-for-service reimbursement. Private plans paid a median of 55–58% of actual costs for patient visits, and 53–74% of costs for LARC method insertion and removal.

While many providers’ experiences varied considerably from these medians, few reported being reimbursed in full. The authors discuss potential pathways for increasing reimbursement rates, for instance by having providers negotiate higher rates where possible or federal regulators doing more to ensure rates are adequate. However, the authors note the complexity of the issue and the significant differences in how rates are set depending on the payer and state where the provider is located.

"Clearly, when so many family planning safety-net providers are not obtaining reimbursement for the full costs of the critical care they provide, it’s problematic and needs to be addressed," says Sonfield. "In the meantime, many of these providers continue to rely heavily on the Title X program to fill in these gaps in reimbursement and stay financially viable. Yet, that money is also needed for serving uninsured clients and for improving quality of care and making it more accessible to those in need, such as through extended hours and tailored outreach."

Title X–supported safety-net health centers rely on a range of funding sources that include reimbursement from Medicaid (about 40% of revenues) and private health plans (8%). Title X grants only account for about 20% of revenues. A separate Guttmacher analysis published in 2015 found that, following the ACA’s implementation, more family planning visits at a group of 32 safety-net centers supported by the Title X program were covered by insurance.

However, despite the well-documented, enduring need for Title X, the program’s funding was cut by 12% between 2010 and 2013, even as the number of women in need grew by 5%. Some in the U.S. Congress are seeking to defund the program altogether. In that context, the authors warn, inadequate reimbursement rates from insurers are a particular threat to the ongoing sustainability of safety-net family planning providers.

Full report: "Assessing the Gap Between the Cost of Care for Title X Family Planning Providers and Reimbursement from Medicaid and Private Insurance," by Adam Sonfield, Andrea Rowan and Rachel Benson Gold of the Guttmacher Institute and Joseph L. Alifante of the New Jersey Family Planning League.

For more information:

Analysis: Title X: The Lynchpin of Publicly Funded Family Planning in the United States