How Important Is the Family Planning Benefit?

One area of controversy over implementation of the Patient Protection and Affordable Care Act (P.L. 111-148) (PPACA) has been the mandate to cover contraceptives. Family planning has also been a hot button issue in Medicaid. And one of the hottest buttons lately has been the exclusion of Planned Parenthood from Medicaid participation.  In Texas, Governor Rick Perry gave up $35 million in annual federal funds in order to exclude Planned Parenthood — leaving the state to run the same program with its own $5 million. The Fifth Circuit upheld the state’s regulations banning family planning providers that so much as use the same identifying mark as an abortion provider, now that the Women’s Health Program is no longer associated with Medicaid.

Indiana also passed a law barring abortion providers from participating in Medicaid. The legislature’s intention to target Planned Parenthood is reflected in the provision that ambulatory surgical centers and hospitals that provide abortion services are not excluded from Medicaid participation. A federal court granted Planned Parenthood an injunction against enforcement of the law, and not long ago, the Seventh Circuit Court of Appeals upheld the injunction. Indiana recently asked the Supreme Court to review the decision– and to use it as an opportunity to keep anyone from suing Medicaid agencies– but that’s another story. It is noteworthy that Indiana’s law was not as restrictive as the Texas law; in Indiana, the creation of a separate legal entity would be sufficient for Planned Parenthood to qualify as a Medicaid provider.

And the lawsuit after enactment of HB 2800 in Arizona resulted in an injunction against the Arizona Medicaid agency barring it from excluding Planned Parenthood simply because it also performs abortions.

Congress has made family planning a priority for many years, in several different ways.

  • It’s a mandatory service, for Medicaid generally and for benchmark and other limited benefits.
  • Presumptive eligibility, a form of expedited access, is available for individuals applying for the family planning limited benefit.
  • No cost sharing may be charged for the services.
  • Even managed care programs must allow beneficiaries to choose their family planning provider.
  • States have long had the option to continue Medicaid eligibility for women who have given birth in order to provide them family planning services.
  • For several years, family planning has been available asa limited benefit, first under waiver programs, and, since PPACA, as an optional basis for eligibility.
  • Federal financial participation for family planning services is 90 percent.

Freedom of choice of family planning provider has been part of the Medicaid statute since enactment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (P.L. 97-248). The same law barred any cost sharing requirement.

Although the legal discussion often centers on the general requirement of free choice of providers at Soc. Sec. Act sec. 1902(a)(23), subparagraph (B) specifies that beneficiaries in managed care programs must have free choice of providers of family planning services, even under waiver programs. This language was added by the Omnibus Budget Reconciliation Bill of 1987 (OBRA) (P.L. 100-203).

Why has the government made family planning a priority? According to the Institute of Medicine report, which also is used to support PPACA’s mandate to cover birth control

  • Unintended pregnancies are discovered later, and prenatal care often is delayed or not obtained at all. Babies born under these circumstances are more likely to be premature and small for gestational age, putting them at higher risk for other health problems.  Planned pregnancies lead to healthier babies.
  • Increasing time between pregnancies helps women stay healthy.
  • Women who have certain medical conditions are at higher risk of complications from pregnancy, such as gestational diabetes.
  • And, perhaps, because controlling the risk of pregnancy is crucial to women’s economic self-sufficiency, i.e., moving out of poverty.