Reversible methods that are available over the counter (OTC) include condoms, spermicides, sponges, and one form of emergency contraception (i.e., Plan B). Pennsylvania covers male (and female) condoms without a prescription, and Washington reported Medicaid beneficiaries can obtain OTC contraceptives at a pharmacy with a Member ID card or at Health Care Authority (HCA) designated family planning clinic. Three states (Alabama, Mississippi, West Virginia) reported utilization controls that mirror those of their well woman visits. Patients will be informed of any rules or regulations that apply to their conduct, as well as diagnosis, treatment options, alternatives, risks and prognosis. Learn about how we help Enrollment and eligibility Learn more about who is eligible for Medicaid and how enrollment works. Private plans and Medicaid expansion programs must cover well woman visits and recommended preventive counseling without cost sharing. Seven states have quantity limits, and five states require the use of the generic levonorgestrel. Learn about the COVID-19 vaccine and booster shots Disaster support We're here to support you during public health emergencies or disasters. Of those, three states have age limits and other medical necessity criteria that must be met (CA, NC, WA).4 Six states do not cover mammograms in their family planning programs (CA, LA, MT, NC, WA, WY). But it's people on a limited income who really feel the squeeze. Maine does not cover bilateral salpingectomy for their Family Planning SPA beneficiaries. While condoms, spermicides, sponges, and Plan B EC are non-prescription products, most states require prescriptions for Medicaid to cover them, and a prescription is required to obtain federal Medicaid matching funds. Alabama Medicaid Twelve of the responding states said they require prior authorization for PrEP and Washington requires prior authorization for brand name HIV PrEP medications only. All the responding states except DC cover preventive counseling on topics like contraception and intimate partner violence. The survey asked state officials about coverage policies for nearly all contraceptive devices and methods, including prescription and non-prescription methods, as well as reversible methods and permanent procedures for women and men. In this survey, eight states said that they cover these services under traditional Medicaid. States that cover permanent contraception or sterilization procedures under Medicaid must meet certain conditions to prevent enrollee coercion. Table 7: State Utilization Policies for Oral Contraceptives, CA and MI limit applies to pharmacy dispensing, AL, CA, IN, MO, MS, NM, OR, SC, TX, VA, WA, AL, CA, MS, SC, TX, VA allowance applies to clinic dispensing only; OR applies only to family planning waiver service recipients, CA limit applies only to extended use oral contraceptives for family planning expansion program, CA limit applies to extended use oral contraceptives only; VT requires prior authorization for non-preferred brand with trial of preferred brand, Table 8: Coverage and Utilization Controls for Other Contraceptive Methods. Federal law requires states to provide certain mandatory benefits and allows states the choice of covering other optional benefits . Alabama Medicaid Click on the questions to see the answers. Emergency contraceptive (EC) pills, sometimes referred to as the morning-after pill, is a form of backup birth control that can be taken up to several days after unprotected intercourse or contraceptive failure and still prevent a pregnancy. *Maryland did not provide a response for reimbursing other providers; Delaware noted that other providers are reimbursed for insertion as part of a global fee, but did not provide a response for the device itself. and sponges purchased OTC, but does not require a . Food, OTC and utility bill credit with Medicare plans Dental - Routine preventive and restorative services . Delaware also requires a prescription for both spermicide and sponge contraceptives, but does not cover male condoms. Having an extended supply has been associated with better access and lower rates of unplanned pregnancy. Mississippi Medicaid Health Benefits Overview For individuals who can get full Mississippi Medicaid health benefits, the following are covered services: office visits family planning services inpatient hospital care outpatient hospital care prescription drugs eyeglasses long term care services inpatient psychiatric care For more details regarding limits and maximum services available, please . Of these states: Colorado allows pharmacy prescribing for OTC products, providing better access to OTC products; Tennessee allows pharmacist prescribing for prescription contraceptives only; and the remaining states cover both pharmacist-prescribed prescription and OTC products. The independent source for health policy research, polling, and news. When will I receive the refund for my Medicare premiums? Maine and Tennessee require that a patient undergo step therapy, meaning they must first try using different oral contraceptives on their PDL before prescribing Drospirenone. PDF Coverage of Over-the-Counter Drugs in Medicaid - National Health Law New York reports they are actively working to include coverage for PrEP for family planning SPA beneficiaries, and Texas requires providers to refer family planning waiver beneficiaries for treatment as necessary. Alaska is the only state that reported not covering well woman visits. If you don't already have this viewer, download for free at Adobe.com . The survey asked states about their policies for ella (ulipristal acetate) and Plan B products (levonorgestrel). The state intends to make system changes in 2016 that will allow separate reimbursement to hospitals for postpartum LARC insertion. Jenna Walls , Many providers have reported that the global fee is not sufficient to cover the costs of providing a LARC postpartum at the time of delivery or at the follow up postpartum visit. As illustrated in Table 11, male condoms and spermicide are covered in 27 of the 41 responding states and the sponge in 26 states. Medicaid Coverage of Family Planning Benefits: Findings from a 2021, Medicaid Coverage of Pregnancy-Related Services: Findings from a 2021 State Survey, Family Planning and Contraceptive Provision Among Females Enrolled in Medicaid, Medicaid Work Requirements: Implications for Low Income Womens Coverage. The absence of a separate or increased fee to cover those LARC and insertion costs has been cited as a disincentive for some providers to offer birthing people the option of choosing a postpartum LARC. The coronavirus (COVID-19) has caused some common OTC items from Superior HealthPlan to have longer wait times to get to . North Carolina reported that many hospitals and physician offices have chosen not to place LARCs in the immediate postpartum period. All three of these states indicated that beneficiaries can receive coverage for family planning services outside of the plan network if their plan has any religious objections. Over the Counter Program - Texas Medicaid & Health Insurance While this program is a state option, all participate. * Medical necessity is included in the count of states with restriction or limitations for IUD and implant removal. Patient courtesy and respect can be expected with all types of Medicaid insurance. It tracks a womans menstrual cycle and identifies days on which they should use protection or abstain from sex. The ACA requires states to cover oral contraceptives for adults in their Medicaid expansion programs (Table 6). Well-woman visits provide an opportunity for women to meet with a clinician to discuss and address preventive health topics. Rebecca Kellenberg , and Texas reported that as long as both the prescribers and the dispensing pharmacy providers were enrolled with the state Medicaid program, the claims would be covered. Coverage of Over-the-Counter Drugs in Medicaid (Revised February 2022) Massachusetts and Indiana will only cover treatment for the partner if they are also a Medicaid beneficiary. For example, Indiana and Vermont limit EPT to gonorrhea or chlamydia diagnoses, and Tennessee covers EPT only for chlamydia. Approaches include separate payments for LARC device as well as clinician fee outside of the global fee. The survey found more variability between states and between eligibility groups for over-the-counter methods, compared to prescription methods. There are three formulations combined, progestin only, and oral extended/continuous use, and many different products within these categories. At least one form of emergency contraceptive pills (levonorgestrel and ulipristal acetate) are covered in traditional Medicaid programs in all but three responding states. KFF Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 Five states apply limitations to Progestin Only Drospirenone (Slynd), a new progestin-only mini-pill that was first approved by the FDA in May 2019, and currently has no generic equivalent. Alabama, Idaho, Indiana, Kentucky, Mississippi, and South Carolina do not provide emergency OTC contraceptive coverage in any of the eligibility pathways available within the state. Virginia and Wyoming reported that they do not cover STI treatment under their family planning waivers. Texas commented that coverage for STI services is subject to retrospective review of medical record and recoupment of payment if documentation does not support the service billed.. Effective October 1, 2013, the Alabama Medicaid Agency will: Effective October 1, 2013, the Alabama Medicaid Agency will begin phasing in the following changes for an effective date of January 1, 2014. Mississippi limits traditional Medicaid beneficiaries to 16 physician office visits per year and family planning program beneficiaries to four office visits per year. This is likely due, at least in part, to the established reimbursement mechanism to pharmacies for prescription drugs. Once a new pharmaceutical has been approved and its manufacturer has entered into a rebate agreement under the federal Medicaid Drug Rebate Program, state Medicaid programs must cover that drug, but may subject it to utilization controls such as prior authorization or step therapy. In April 2016, CMS issued a bulletin addressing reimbursement for LARC devices. See if you qualify for these plans. Medicaid, DSNP & CHIP Plans by state - Health insurance plans for To: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, Hospitals, and Nursing Homes. These requirements are intended to protect against coercive practices that had historically forced sterilizations upon marginalized groups, including low-income women, women with disabilities, women of color, and incarcerated women. In Hawaii, abortion services are carved out and paid through their fee-for-service fiscal intermediary, while contraceptives are billed through the managed care plans. CMS Bulletin on Payment Approaches for LARCs. 4.8 Satisfied 52 votes How to fill out and sign kepro online? Prescription Drugs - Medicaid All states report that they cover tubal ligation when the fallopian tube is cauterized or clipped (postpartum and general), bilateral salpingectomy when the fallopian tube is removed, and vasectomy services. Appendix Table A2 provides state response detail around 12 month supply dispensing and utilization controls for oral contraceptives. Carrie Rosenzweig , Contraception can either be delivered to a clients home or be picked up at a local pharmacy. For example, in Texas the claim for the product must be accompanied by a family planning diagnosis code. Medicaid Coverage of Family Planning Benefits: Findings from a 2021 Food, OTC and Utility Bill Credit | UnitedHealthcare Community Plan For example, Virginia restricts access to all three OTC types to pharmacy dispensing only with a prescription. Sign in to MyHumana . Appendix Tables A5 and A6 provide additional detail on state coverage of OTCs and utilization controls applied and coverage of OTC contraceptives in each of the eligibility pathways. Kathy Gifford Illinois reported that plans must have contracted facilities nearby that can provide family planning services. Pap tests and HPV DNA testing are used to screen for cervical cancer, while colposcopy and LEEP or cold knife conization are follow-up services used after an abnormal screening result. Under federal law, and subject to exceptions for a few drugs or drug classes,1 state Medicaid programs are required to cover all drugs from manufacturers that have entered into a rebate agreement with the Secretary of Health and Human services under the federal Medicaid Drug Rebate program (known as covered outpatient drugs). Alabama Medicaid Agency's Prior Authorization Program and Preferred Drug List (PDL) 7 8. Texas does not cover any form of emergency contraceptive pill under their limited scope family planning program. In the case of ella, which requires a provider prescription, fewer states apply utilization controls across states compared to Plan B OTC products (Table 10). However, it is not clear how Medicaid coverage of the app works, whether it is considered an OTC product or if clinicians are writing prescriptions for the app. However, this requirement does not apply to those covered under traditional Medicaid or those enrolled in limited scope family planning programs where states have the option whether to cover specific STI screenings and treatments. Sterilization procedures, or permanent contraception, are among the most effective methods of contraception. Authorization for Foster Parents and Related Caregivers to Apply for WIC Benefits 6 7. Compared to the 2015 survey, more states report providing separate reimbursements to clinicians and hospitals for postpartum LARC insertion. The state must also ensure that the full costs of family planning services are covered and that MCO-enrolled beneficiaries are able to see any Medicaid provider of their choice, even if the provider is not in the MCOs network. Colorado and Tennessee use the global maternity fee to reimburse hospitals for both the device and insertion. Learn About Medicaid Coverage In Alabama - Medicaid-guide.org Reversible methods include a wide range such as long-acting reversible contraceptives (LARCs) intra-uterine devices (IUDs) and implants; oral contraceptives; injectables, emergency contraceptives; and various other products and devices available by prescription or over-the-counter (OTC). Oregon reported that they currently allow a 100-day supply and that a system change is in development to allow for a 12-month supply. Alabama Medicaid Michigan provides EPT outside of the Medicaid program through their Department of Health and Human Services HIV/STI program to all regardless of insurance status. New over-the-counter hearing aids could be a low-cost solution . The ACA requires coverage of these benefits in Medicaid expansion programs. In recent years, a number of companies have created new products to dispense contraceptives outside of a clinical setting or a brick-and-mortar pharmacy and have applied technology to older contraceptive methods such as using an online app to track fertility using a calendar method. Learn about Benefits & Services available from Superior HealthPlan for health . These utilization controls include preferred drug lists (PDL), requiring the use of generics before brand name drugs, step therapy protocols, and prior authorization. Under the ACA, full scope Medicaid expansion pathways must cover prescription methods, but the requirement does not apply to over the counter methods. Benefits content loading. OTC allowance benefits vary by plan and are plan specific. If a state chooses to cover OTC drugs, a prescription is required to access federal Medicaid matching funds (although a state could choose to use state-only funds to cover OTC products without a prescription). Labor and delivery is typically reimbursed through a global fee that covers the costs of all maternity care, including labor and delivery services, and postpartum care. States were asked how they structure reimbursement to clinicians and hospitals for LARCs inserted immediately after labor and delivery. Like contraception, Medicaid expansion states must cover these services for their expansion populations, but coverage is not required in traditional Medicaid or family planning programs. , and The state covers wellness checks through age 20 only. Prior KFF study found that most companies reported encountering barriers trying to work with state Medicaid programs. Three statesCalifornia, Missouri, and Washingtonalso allow coverage of a 12-month supply of the 28-day vaginal ring and the hormonal patch, and Washington covers a 12-month supply of the injectable contraceptive. California allows only clinics to dispense injectable contraceptives, but restricts dispensing of diaphragms to pharmacies. Virginia, which also uses a global reimbursement methodology, described a four month pilot project implemented by one of its managed care plans that allowed for separate payment for the LARC device. Table 9 State Coverage of Emergency Contraceptives, by Type of Program, AL, ID, SC do not cover either ella or Plan B in traditional Medicaid; AL and SC do not cover in family planning waiver/SPA, Table 10: State Utilization Controls for Emergency Contraceptives, AK, AR*, AZ, CA, CO, CT, DC, DE, HI, IA, MA, ME*, MI, MO*, MT, NC*, NH, NM, NV, OH, OK, TN*, TX, VA, VT*, WV*, WY. Some states impose utilization controls on emergency contraception such as age and quantity limits. All states participating in the survey cover all LARC methods through all of their Medicaid programs offering family planning services (Table 3). The USPSTF recommends services to help prevent both cervical and breast cancers. Alabama Medicaid All responding states cover daily use oral contraceptives (Combined, Progestin only, as well as Oral Extended and Continuous use) regardless of the eligibility pathway. The independent source for health policy research, polling, and news. Under this program, the state covers screening services if they are provided along with a contraceptive visit. OTC credit with Medicare Advantage plans - UnitedHealthcare A couple of states noted that they apply the same or similar utilization controls to postabortion contraceptives that they apply to contraceptives obtained in other situations. Preventive counseling is an important component of well woman care. Delaware manages hormonal IUDs on a PDL, and five states (Michigan, Missouri, Montana, Pennsylvania, and Vermont) impose quantity limits on LARCs based on a specified timeframe that is aligned with FDA guidelines. Eleven states reported that they restrict the quantity of oral contraceptives per prescription to a three-months supply (Table 3). Federal law does not require states to cover most over-the-counter (OTC) drugs, with the exception of nonprescription prenatal vitamins, fluoride preparations for pregnant people, and certain nonprescription tobacco cessation products. Thirty-four states provide separate reimbursement to the clinician for the LARC insertion procedure and LARC when placed immediately after labor and delivery while in the hospital or birthing center, while five states include the reimbursement to the clinician within the global fee structure. The program covers a wide range of benefits, including screening, prevention, prescription drugs, and treatment services. Illinois Medicaid covers OTC products in limited quantities and in Oregon, pharmacists can prescribe Plan B. DC, Illinois, Maryland, New Jersey, New York, Utah and Washington reported covering OTC emergency contraceptive pills without requiring a prescription, although DC only covers OTC emergency contraception under its traditional Medicaid program and not through its limited scope Medicaid family planning program. Appendix Table A1 provides detail for each state response. Medicaid Plans, Medicaid Insurance - Humana | Find Medicare Plans and Vermont requires prior authorization for non-preferred brands, along with a trial of a preferred brand. This has been the source of considerable research, public health education, and policy activity in recent years in part because data that suggests birth spacing is an important component of healthy pregnancies and optimal birth outcomes.1 LARCs are among the most effective forms of reversible contraception and research suggests that providing them during the postpartum period, either at the time of delivery or at the follow up visit can help lower the rate of unintended pregnancies. Just three of these states, Illinois, Maryland, and Washington, cover all four of these methods without a prescription. Most states require a prescription for Medicaid to cover any of these methods. Medicaid Coverage of Family Planning Benefits: Results from a State The USPSTF recommends that clinicians offer risk-reducing medications to some women at higher risk for breast cancer. Nearly all (40 of 41) of the responding states cover genetic (BRCA) screening and counseling for high-risk women in their Traditional Medicaid program. Occupational, speech or respiratory therapy for beneficiaries 21 years of age or older. Thirty states reported providing a separate hospital reimbursement for a LARC device placed immediately after labor and delivery. All, but one, of the responding states cover the HPV vaccine for adults in their traditional Medicaid program. All responding states cover at least one form of emergency contraception pill under their traditional Medicaid program. All states cover the follow-up cervical screening services, colposcopy and LEEP or cold knife conization under traditional Medicaid, but some do not cover these services under their limited scope family planning programs. Descovy is not approved for use as PrEP in females who are at risk for HIV through vaginal sex. All states surveyed cover all forms of oral contraceptives in their traditional Medicaid program and their family planning waiver or SPA as applicable. Other restrictions pertain to the type of provider that can provide or dispense the contraceptive. Georgia Medicaid Pharmacy Benefits - Peach State Health Plan Member Resources OTC Benefits - Medicare How To Use Your Anthem Medicare Advantage Benefits Prepaid Card For Your Over-The-Counter Benefits Thanks to Anthem BlueCross BlueShield, you receive benefits on many over-the-counter (OTC) health items you use every day. PrEP medications, which were first approved by the FDA in 2014, prevent individuals from acquiring HIV. In the context of family planning, the covered outpatient drug requirements affect coverage of and access to contraceptives, treatments for sexually transmitted infections (STIs), and preventive medications for conditions such as breast cancer and HIV. New York reported that beneficiaries can access Plan B at the pharmacy counter, and the pharmacist can then bill Medicaid in absence of a prescription. A few states reported covering 12-month supplies of these prescription contraceptives. How do I get my medications? Your OTC benefit helps you save money on a wide range of over-the-counter health and wellness products. Three states indicated no specific hospital reimbursement for post labor/delivery LARCs. We asked states if they include family planning services within MCO capitation rates and whether they claim the enhanced 90% FMAP for family planning services purchased by MCOs. None of these states reported requiring prior authorization for the devices. A dozen states report prior authorization requirements for PrEP medications.
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