States can improve and expand access to contraception by broadening eligibility for their family planning program services, which would allow people who are not eligible for full Medicaid coverage to still receive coverage for specified family planning services and visits.
Expansions can be done through 1) a Section 1115 waiver—also known as a “demonstration project”—or 2) a permanent state plan amendment (SPA). Waivers are temporary, limited-scope projects that allow states to pilot new approaches and initiatives that do not meet federal standards or that extend beyond federal options. SPAs are permanent changes to a state’s Medicaid plan that create a new family planning eligibility group entirely.
Common challenges to implementing a new Section 1115 waiver or SPA include patient awareness and outreach, ease of enrollment, compliance with the freedom-of-choice provision, and robust data collection and evaluation.
Introduction and summary
Medicaid is the largest payer of reproductive health services in the United States,1 paying for more than 40 percent of all births in 20192 as well as a large portion of births for women of color, including 65 percent of births to Black women.3 The program also covers a greater proportion of births to women living in rural areas and women with lower educational attainment.4 Medicaid is a vital support to so many Americans, and its role in access to family planning, reproductive health services, and maternity-related care cannot be understated.5
Since 1972,6 family planning has been a mandatory benefit under Medicaid standard benefit plans,7 which means that states are required to cover “the delivery of family planning services and supplies.”8 This definition offers states considerable discretion and flexibility in the specific services that are included in the program and is one of the reasons there is such variability in family planning coverage across states.
Medicaid is a jointly funded federal and state partnership that provides health insurance to individuals and families who meet certain eligibility criteria.9 In particular, Medicaid may cover people with low incomes, people who are pregnant, youth and young adults, and people with disabilities. Since the beginning of the COVID-19 pandemic, Medicaid enrollment has skyrocketed,10 with more than 90 million people enrolled in their state Medicaid and Children’s Health Insurance Program (CHIP) programs in September 2022.11
Last December, Congress set an end to the continuous enrollment requirement, which gave states enhanced federal funding during the COVID-19 public health emergency. This additional support will end officially on April 1, 2023, forcing states to resume normal eligibility determinations. An estimated 18 million people could lose coverage as a result.12
Contraception is one of the primary services included under family planning. Most states provide broad coverage13 for prescription contraceptives,14 testing and treatment for sexually transmitted infections (STIs), and prevention and diagnostic screenings for cervical and breast cancer.15 States could further improve and expand access to contraception by expanding eligibility for their family planning program services. This could be done by pursuing a temporary Section 1115 waiver—also known as a “demonstration” or “demonstration project”—or a permanent state plan amendment (SPA). The use of Family Planning Only waivers and amendments to expand access to family planning services, including contraceptives, has become more widespread over the past couple of decades. This is in part due to an Affordable Care Act provision that allows states to permanently expand coverage of family planning services through a SPA, which has resulted in more states phasing out their Section 1115 waivers in favor of SPAs, giving a permanent change to states’ Medicaid programs.16
Twenty-eight states have expanded access to family planning services through waiver demonstrations and SPAs, and three states—Iowa, Missouri, and Vermont—have their own state-funded family planning programs.17 Medicaid expansion is necessary to make family planning services available and to ensure continuous coverage of contraceptive care. All 28 states noted above use income thresholds to determine eligibility, with thresholds ranging from 138 percent of the federal poverty level (FPL)—in Louisiana and Oklahoma—to 306 percent of the FPL, in Wisconsin. Each state has its own eligibility criteria beyond these income thresholds. For example, some states may exclude men and young people from their programs, while others allow individuals to become eligible if they have lost their Medicaid coverage for any reason (Florida) or have lost coverage postpartum (Rhode Island, Wyoming).
Table 1 provides a closer look at states’ family planning programs and eligibility requirements.
About state plan amendments
SPAs permit states to receive federal funding for coverage that does not meet federal standards or that extends beyond federal options. A SPA is a permanent change to a state’s Medicaid program in which the state plan defines who is eligible, what services are provided, how providers are reimbursed, and what administrative activities are underway in the state.18
Although a state must still obtain federal approval for a SPA, the process for securing such approval is generally faster and more streamlined than that for a waiver. Moreover, pursuing a family planning SPA is typically preferable to a waiver because it can be taken up quickly—as soon as 90 days from its submission to the Centers for Medicare and Medicaid Services (CMS). There is also no public comment period,19 as is required for a Section 1115 waiver, and SPAs are also not required to be budget neutral,20 ensuring that states can receive a regular federal matching rate for beneficiaries rather than having to cap federal spending at a pre-waiver baseline. Perhaps the greatest benefit of a SPA, however, is that it represents a permanent change to the state’s Medicaid program, and so, all policy and political efforts to adopt the amendment cannot be easily undone by a new state administration. Since federal guidelines have opened the option for states to permanently change their plans through SPAs, 18 states have transitioned to a family planning SPA, the most recent being Colorado offering limited family planning coverage.21
Several restrictions that have been applied to family planning waivers in the past do not apply to SPAs. For example, states may use an enrollment strategy known as presumptive eligibility, through which an applicant may be granted immediate temporary eligibility by a qualified health care provider.22 Although documentation for various factors of eligibility—such as citizenship—is required to convert temporary eligibility into full enrollment, such documentation is not required for the presumptive determination.
Read the accompanying fact sheet
About Section 1115 waivers
Section 1115 waivers allow states to experiment with or pilot new approaches23 and initiatives that do not meet federal standards or that extend beyond federal options.24 The purpose of Section 1115 waivers is to give states additional flexibility to design and improve their programs. Waivers are time-bound and limited-scope; generally, they are approved for an initial five-year period,25 but they can be extended for up to an additional five years, on a state-by-state basis.
While it is generally more favorable for states to pursue family planning SPAs for the reasons mentioned above, waivers are a beneficial option for states looking to test out new approaches or implement new initiatives. This option was intended for states to test novel ideas, gather information, and assess impact to further inform their family planning goals and priorities. Unfortunately, states sometimes misuse waivers,26 pursuing them as cost-cutting measures or to evade federal requirements, rather than the waivers’ intended purpose.27
As part of a waiver approval, states must agree to perform periodic reviews of the implementation of a project and have reporting requirements. Waivers also have a budget neutrality requirement, meaning that a state and the federal government have to agree that federal spending with the waiver—known as the “WW baseline”—will not be higher than projected federal spending without the waiver, or the “WOW baseline.”28 Typically, the process for obtaining a Section 1115 waiver is lengthy and complex.
Research demonstrates that family planning waivers are beneficial for increasing access to family planning services, reducing unintended pregnancies, and helping women plan their families if, when, and how they choose.
Research demonstrates that family planning waivers are beneficial for increasing access to family planning services, reducing unintended pregnancies, and helping women plan their families if, when, and how they choose.29 A 2004 CMS-commissioned evaluation of family planning waivers in six states—Alabama, Arkansas, California, New Mexico, Oregon, and South Carolina—found that each state achieved annual cost savings, ranging from $1.3 million (in New Mexico) to more than $76 million (in California).30 More than 10 years later, a 2015 study of family planning waivers in three states—Illinois, New York, and Oregon—found that waivers specifically decreased unwanted and mistimed pregnancies and increased postpartum contraception use; however, the authors noted that effects can vary across states depending on eligibility requirements and comprehensiveness of services.31 In particular, the study found that family planning demonstrations may have a greater impact on youth under the age of 21. This suggests that states may find it beneficial to explore demonstrations that serve youth as a way to reduce youth pregnancy and increase use of contraception. Through these programs, states can save money while also increasing access to services. Further research has shown that family planning expansions either yield financial benefits or, at the very least, are cost neutral.32
Case studies: Approaches to implementing waivers and state plan amendments
There is no one standard way for states to enact and design a family planning expansion. It depends on each state’s unique family planning context and goals, which typically are to reduce unintended pregnancies and achieve greater cost savings. Additionally, states have considerable discretion and flexibility in choosing the components of their programs, including which populations and which services are covered. More than half of states have expanded their family planning services to people who otherwise would not be eligible for Medicaid coverage through established family planning programs.33
The following case studies are not intended to be comprehensive—and the recommendations below describe additional statistics from states to further explain the need for certain changes—but these examples demonstrate some notable trends in implementation.
In 2008, North Carolina introduced a strategic plan to reduce infant mortality by improving women’s health.34 A few years later, in 2013, the state began a family planning waiver demonstration project called “Be Smart,” with the most current iteration running from 2018 to 2023.35 This program provides family planning and family planning-related services to people of all genders at or below 195 percent of the FPL with no age restrictions.36 Services include annual exams, family planning visits and counseling, HIV testing and STI screenings, and some contraceptive methods.37
After conducting a consumer survey in 2018, North Carolina found that almost 40 percent of program enrollees were not aware of the services offered, signaling a need for greater awareness of the program and its offerings. They set out an ongoing six-part strategic plan to address gaps in awareness and service utilization.38 The plan outlined six strategies for implementing and scaling the program effectively, which included 1) expanding partnerships for program services; 2) increasing opportunities for training for agencies and program partners; 3) providing training and outreach; 4) improving the enrollment eligibility determination process; 5) creating an easy enrollment process; and 6) improving transitions from existing Medicaid programs for providers and beneficiaries.
Wisconsin’s family planning program covers contraceptive services and supplies, natural family planning supplies, routine preventive primary services, STI tests and treatment, and more if provided at a family planning visit.39 Wisconsin transitioned from a waiver to a SPA in November 2010. During its waiver period, the state covered individuals with incomes under 200 percent of the FPL. After transitioning to a SPA, Wisconsin expanded the eligibility criteria to 306 percent of the FPL.40 Research estimates that between 10,600 and 18,800 new participants may have gained family planning coverage due to the SPA transition.41 Increasing the income eligibility threshold is a highly important factor. Because states often follow a cascading eligibility model, even if beneficiaries do not meet the criteria for full Medicaid coverage, they may still be eligible for family planning services coverage since higher income thresholds increase access for more people. In fact, one study found that after transitioning from a waiver to a SPA, Wisconsin and other states saw an increased likelihood of receipt of postpartum contraception.42
As of February 2023, Colorado was the most recent state to submit a SPA for a family planning expansion. Its Department of Health Care Policy and Financing will cover all family planning services and supplies, except those related to infertility. While that program is still in its infancy, Colorado does have a successful, long-standing family planning initiative run by the Colorado Department of Public Health and Environment (CDPHE).
In 2008, the state launched a targeted family planning initiative with an emphasis on improving access to long-acting reversible contraceptives (LARCs).43 The initiative received private funding for purchasing LARCs, training for health care providers, and support for operational, administrative, and outreach activities. Previously, Colorado had been working on a Medicaid waiver application for nearly 10 years. Given Colorado’s diverse population and demonstrated need for more family planning services and access to contraceptives, the state was well-situated to implement the LARC program.
Data show that nearly 40 percent of all pregnancies in Colorado were unintended pregnancies prior to implementing the CDPHE program in 2009.44 In its first five years of operation, the program had demonstrable impacts on pregnancy rates and cost savings for public programs. Medicaid costs associated with the averted births are estimated to amount to up to $53.7 million.45 Moreover, the teen (ages 15–19) birth rate was reduced by 50 percent, and the young women’s (ages 20–24) birth rate was reduced by 20 percent.
Challenges and solutions
More than half of states have opted to expand their Medicaid family planning coverage options through either Section 1115 waivers, SPAs, or, in some cases, their own state-funded programs. While pursuing a waiver involves a different process compared with a SPA, there are still many factors that states must consider for both avenues, including patient outreach and awareness, ease of enrollment, compliance with the freedom-of-choice provision, and robust data collection and evaluation.
Challenge: Patient awareness and outreach
To reach out to new patients as well as inform existing ones of changes to Medicaid programs, state agencies must consider options that are practicable, accessible, and effective. States have used several methods to increase patient awareness, ranging from program websites and advertisements, phone hotlines, and provider outreach and relationship-building with other health services programs.46
In particular, they should pursue the following strategies:
- Directly reach out to people who are currently enrolled or have previously been enrolled in public insurance programs and resources, such as family planning centers. For instance, some states have opted to work with family planning centers to engage existing clients who meet the specified eligibility criteria, which can also be beneficial for patient retention and enrollment.47 Researchers have found that “community-based outreach is … an approach that both saves the state money and takes advantage of family planning providers’ knowledge of the local communities.”48 For example, as part of Alabama’s most recent education and outreach activities, the state distributed outreach materials through “maternity care providers, health departments and safety net providers.”49 This is a continued strategy that Alabama has used to conduct outreach to target populations.50
- Adequately fund and staff hotlines and establish an easily accessible programming website for people to get more information. While these are more passive forms of outreach activities, they are still useful for people seeking information.
While its waiver is no longer in place, Michigan used to run a family planning demonstration called Plan First!, offering an interesting example of how social media marketing and campaigning can be used to reach potential enrollees. Part of Michigan’s outreach plan consisted of targeted ads on social media websites.51 The state used an interactive service called Clearspring that used key words, such as “birth control,” to prioritize Plan First! information in search results. This strategy also allowed the state to track traffic results to the website and could always be adapted to fit the most relevant social media platforms used by states’ Medicaid populations.
Challenge: Ease of enrollment
States may use a variety of methods—such as online applications, automatic enrollment, and presumptive eligibility—to enroll people in their family planning programs. Facilitating a smooth enrollment process is crucial to having a well-utilized program and ensuring that patients are not discouraged by or forced to go through unnecessary hurdles. Additionally, making the application and enrollment processes easier can help states reach populations that are disproportionately uninsured or underinsured and lack coverage for a variety of reasons.
Specifically, states can take the following steps:
- Use automatic enrollment to help facilitate a smooth transition for people who are losing full Medicaid coverage but are still eligible for coverage under a Family Planning Only program, which most often happens during a small postpartum window. In 2011, researchers found that 8 of 19 states at the time had eliminated the application process altogether for certain groups of people who were losing full Medicaid coverage and instead automatically enrolled them in a family planning program.52 While this strategy can be beneficial, it also requires states to perform a quick uptake and robust communication strategy to notify patients of their new care plan and eligibility. In many such circumstances, the benefits can go unutilized because of inadequate infrastructure to keep track of enrollees and minimal follow-up and outreach efforts.
- Utilize providers as a point of outreach for enrollment. Some patients may prefer to apply for benefits in person with an available provider. In doing so, patients can apply for the program and receive services at the same time.
- Use of presumptive eligibility in Medicaid enrollment. This process allows health care providers to determine that a patient is temporarily eligible for coverage, with applications for ongoing coverage processed later by the state. Even if the application is later rejected, the provider is reimbursed for services that have been provided. For example, Minnesota—which formerly implemented a waiver program and has since transitioned to a SPA—used presumptive eligibility to determine enrollment.53 A provider would screen a patient for eligibility using preliminary information. Based on that information, the provider would determine if that person met the eligibility requirements and, if so, provide services. The department would determine ongoing eligibility.
Challenge: Compliance with the freedom-of-choice provision
Under the freedom-of-choice provision, Medicaid enrollees have the right to receive family planning services from any qualified provider,54 enabling women to receive those services from a Medicaid provider of their choice. This is true even for people enrolled in managed care plans, which typically limit the providers available in a network.55 Women still should have the “freedom of choice” to go to any provider without cost-sharing.
However, studies have found that this provision is generally not well understood by enrollees and sometimes ignored by states, and thus patients are not able to take full advantage of their options.56 Furthermore, some states have excluded providers that offer abortion services from participating in Medicaid,57 even though these providers are sometimes a main source of comprehensive family planning services.58
Moving forward, states should be careful that they:
- Don’t carve out or restrict certain family planning providers from care through waivers or SPAs. For example, researchers have reported instances where some beneficiaries have been incorrectly told that they are not eligible to see out-of-network family planning providers.59 This has been accompanied by reports from providers that they experience more challenges with receiving reimbursement when working with patients from out of network.
As mentioned above, some states—namely Texas, Tennessee, and South Carolina—have implemented or applied for a waiver that unfortunately restricts reproductive and sexual health services under Medicaid. In particular, Texas submitted a waiver for the provision protection to exclude abortion providers.60
Challenge: Robust data collection and evaluation
The impact of comprehensive data cannot be understated, as they can encourage family planning expansion programs and uptake in other states. It is therefore important for states that receive a Section 1115 waiver to monitor and conduct evaluations of their program data and provide quarterly and annual reports to CMS. However, reporting is not always consistent, and in recent years, programs have had to halt their evaluations due to the COVID-19 public health crisis. Indeed, there is a need for more consistent, up-to-date, reliable, and comprehensive data on Medicaid and family planning. Additionally, states that have transitioned to a SPA are not required to follow the same reporting guidelines as waiver states, meaning that, sometimes, data are even more sparse.
As noted in a six-state analysis,61 most states lack comprehensive data on Medicaid family planning, making it difficult to definitively draw conclusions and assess the full impact of their programs. While some research indicates that family planning programs increase utilization of contraception and cost savings while decreasing unintended pregnancies, most states do not have robust data collection, evaluation, and reporting measures. Accordingly, states must:
- Conduct data collection and evaluation measures through state departments of health or contract with outside organizations, such as local universities and research institutions, to be independent evaluators. Alabama collaborated with the University of Alabama at Birmingham to conduct the first evaluation of its family planning program.62 As part of ongoing monitoring, the evaluation plan uses claims data and participant surveys to review issues such as reasons for not using family planning services, choice of birth control, services accessed during family planning visits, and use of care coordination services.
Another notable program evaluation was California’s partnership with the University of California, San Francisco (UCSF),63 which was discontinued in 2016 and taken over by California’s Department of Health Care Services. UCSF developed a series of annual reports on various program components, such as beneficiaries’ enrollment, services provided, and more. Other states looking to implement a robust evaluation of their family planning programs can look to California’s model for contracting with other agencies that may have capacity, resources, and specialty in a given area.64
As the largest payer for reproductive health services in the United States, Medicaid is a necessary and vital public program for pregnant and postpartum women, low-income women, uninsured or underinsured women, women of color, and disabled women. States that have expanded family planning benefits under Medicaid have seen benefits such as increased cost-effectiveness and decreases in unintended pregnancies. While Section 1115 waivers and state plan amendments both have their benefits and drawbacks, each offers a way to make meaningful change for not only access to birth control but other crucial preventive services.
The author would like to thank Osub Ahmed, Bela Salas-Betsch, Amina Khalique, Elyssa Spitzer, Maggie Jo Buchanan, Sabrina Talukder, and Emily Gee for their contributions to and reviews of this series.