Your Family Tree

Family planning services and supplies have been a part of the Medicaid program since it was first established half a century ago. And over the past several decades, Medicaid has become the dominant public funding source for family planning in the United States. That should not come as a surprise, given the demographics of the population that Medicaid insures: According to unpublished tabulations of U.S. Census Bureau data, 20 percent of U.S. women of reproductive age (15–44) are enrolled in Medicaid, including 47 percent of those living below the federal poverty level.

This spring, the Centers for Medicare and Medicaid Services (CMS) turned an unprecedented amount of attention to these issues, recognizing Medicaid’s importance in enabling low-income women to access the family planning care they need. Sweeping governing the involvement of private-sector managed care plans in the Medicaid program and of guidance to state officials focusing exclusively on family planning together form the most comprehensive set of rules, principles, and recommendations for states that CMS has offered on the subject.

Free Choice of Services

Since 1972, federal law has required all state Medicaid programs to cover family planning services and supplies for all enrollees of reproductive age, and to do so without copayments or other forms of patient out-of-pocket costs. expand on that requirement, making it clear that Medicaid enrollees must be “free from coercion or mental pressure and free to choose the method of family planning to be used.”

Beyond those basic rules, however, states have traditionally had considerable leeway in deciding which family planning services and supplies would be covered under Medicaid. States have sometimes imposed, or allowed Medicaid managed care plans to impose, additional restrictions on enrollees’ choice of methods and services in the name of controlling utilization and costs.

This started to change with the Affordable Care Act (ACA). People newly eligible for Medicaid under the ACA’s Medicaid expansion are enrolled in Alternative Benefit Plans (ABPs), which are designed to mirror private-sector health plans and therefore must comply with the ACA’s requirement to cover a wide array of recommended preventive services without cost-sharing. That includes contraceptive counseling and services and every contraceptive method for women (currently 18 of them) recognized by the .

CMS has not required states to cover the same list of contraceptive methods for traditional Medicaid enrollees. But in a, the agency recommended that states cover every contraceptive method, including both prescription and over-the-counter methods, arguing that “because not all forms of contraception are appropriate for all beneficiaries, in the absence of contraindications, patient choice and efficacy should be the principal factors used in choosing one method of contraception over another.”