Our Medicaid Commitment to Family Planning

Illinois Contraceptive Equity Summit
Julie Hamos, Director
August 20, 2014

Medicaid and Pregnancy

Total Medicaid enrollment as of 7/1/14: 3,070,432

• About 1 million girls and women on Medicaid are of childbearing age (13-49 years old)

• IL Medicaid pays for 94% of teen pregnancies

• IL Medicaid pays for 54% of all pregnancies

Governor Quinn on Hobby Lobby Decision

“Healthcare is a human right, and the Affordable Care Act is meant to give all Americans access to decent, affordable healthcare. That means full access to healthcare for every woman in America, regardless of who they are or where they work.

“A woman’s personal health decisions should stay strictly between her and her doctor. Unfortunately, the U.S. Supreme Court’s decision takes these choices from a woman and gives them to her employer.

“We will continue to fight to preserve the right of Illinois women to make their own healthcare decisions based on their own beliefs, not the beliefs of the person signing their paycheck.”     

6/30/14

IL Family Planning Action Plan

Today we are announcing the

Illinois Family Planning Action Plan – IFPAP

Our goal:

Increase access to family planning services for women and men in the Medicaid Program by providing comprehensive and continuous coverage to ensure that every pregnancy is a planned pregnancy.

Actions To Accomplish Goal

• ACTION #1: Payments and operational policies should reflect the value HFS places on providing the most effective form of contraception.

• ACTION #2: Health plans and providers in the Medicaid Program should make all family planning options available to Medicaid clients in a convenient and seamless manner.

Medicaid Family Planning Policy

• June 26, 2014 provider notice articulated policy; updated provider notice released November 10, 2014

• All Medicaid providers must provide full spectrum of family planning options, with no cost sharing

• Free Choice of Provider statute allows clients to see any Medicaid provider of their choice – with no managed care restrictions

• Clients should receive education and counseling on all FDA-approved birth control methods, from most effective to least effective, with most effective presented first: long acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and implantable rods

• Contraceptive methods must also include over-the-counter and prescription emergency contraception

• LARCs and emergency contraception were most directly threatened by Hobby Lobby decision

LARC Policy in Colorado

• Research shows that LARCs are safe and effective for women and girls of all ages

• Colorado Department of Public Health and Environment had initiative to help low-income women get LARCs

• Impressive results:

  • Teen birth rates dropped 40% from 2009 through 2013

  • Teen abortion rates dropped 35% from 2009 to 2012

  • Infant caseload for Colorado WIC fell 23% from 2008 to 2013

  • Total CO state savings in 2010 alone – $42.5 million

Action #1:  Changes in HFS Rates & Operational Policies

• Double the provider reimbursement rates for IUDs and vasectomies

• Increase 340B providers' dispensing fee (completed)

• Allow medical provider reimbursement for two services on the same day when visit includes a LARC procedure and an initial or annual exam or problem visit

• Allow FQHCs to bill fee-for-service for permanent, non-surgical sterilization kits (Essure)

• Investigate allowing hospitals to bill for LARC insertion immediately postpartum

Action #2:  Providers to Make Family Planning Accessible

• Require all providers to submit family planning policies annually to HFS, including referral policies from those which invoke Right of Conscience objections

• Continue working with LARC companies to ensure adequate inventory for same-day insertion, with ongoing training program

• Communicate to Medicaid providers that:

  • Clients must receive evidence-based counseling and education about all FDA-approved contraceptives

  • Cost sharing, step therapy failure requirements and prior authorization are not allowed

  • HFS will make timely payments to doctors and FQHCs, and will require health plans to make timely payments.

Medicaid Vision Aligned with ACA

• We are increasing access to care

  • 620,000 more IL residents have health coverage

  • 414,000 are newly Medicaid-eligible adults – including women without children under 138% FPL ($16,104 annual income)

• We are working to fulfill the "Triple Aim"

  • Improving the quality of care

  • Improving the health of populations

  • Reducing the growth in healthcare costs

Illinois State Mandate

• 2011 Medicaid reform law (P.A. 96-1501) mandates 50% of clients to be enrolled in "care coordination" by 1/1/15

• Even without state mandate, we believe that care coordination is needed to achieve the Triple Aim

• We use "care coordination" and "managed care" interchangeably – it's about "managing" care

• Care coordination requires redesign of Medicaid Program

Why Medicaid Redesign Is Needed

• Clients must search for providers willing to accept Medicaid, with little help in navigating a fragmented system

• Providers operate in "silos," with few incentives to coordinate services or create multidisciplinary teams

• The client's holistic needs are not considered: medical, behavioral health and social needs

• Fee-for-service payments reward volume of services rather than value

Care Coordination Roll-Out Plan

• Clients are currently enrolling or being enrolled in Health Plans in 5 mandatory regions

  • Greater Chicago region – 6 counties

  • Rockford region – 3 counties

  • Central Illinois region – 15 counties

  • Quad Cities region – 3 counties

  • Metro East region – 3 counties

• Clients in rural counties will continue in fee-for-service

• About 2 million of 3 million Medicaid clients will be in Health Plans by early or mid-2015

Illinois’ Unique Structure

• Variety of managed care entities will have Health Plans for different Medicaid populations

  • Managed Care Organizations (MCO) – 9 total

  • Managed Care Community Networks (MCCN) – 2

  • Care Coordination Entities (CCE) – 6

  • Care Coordination Entities for Children with Special Needs (CCE-CSN) – 2

  • Accountable Care Entities (ACE) – 9

• All of these entities could have members who are women and girls of childbearing age

What the New World Means for Family Planning Providers

• In 5 mandatory regions, providers must be part of Health Plans

• Health Plans must ensure that providers are offering comprehensive family planning services

• Providers will be paid by Health Plans, not the State (long-term)

• Health Plans/providers exerting Right of Conscience must offer referrals that are accessible

• State will monitor Health Plans to ensure that family planning services are comprehensive and accessible

Illinois Healthy Women Family Planning Waiver

• IHW Waiver provided family planning services for women not eligible for Medicaid (up to 200% of the Federal Poverty Level) for over 10 years from 2004-2014

• IHW was phased out December 31, 2014, because full health coverage is now available (and required) under ACA

Health Coverage Now Available

• Women with no dependent children and with income up to $16,104 (single) or $21,707 (family of 2) qualify for Medicaid

• Women who previously qualified for IHW – income under $23,340 (single) or $31,460 (family of 2) – can now buy private health insurance through the Marketplace, with tax subsidies

• For example, a woman earning $23,340 will pay at most $125 per month on premiums for Silver Plan coverage – or 6.4% of her income

Join Us As Partners

• Review Illinois Family Planning Action Plan and offer feedback/comments

• Help develop strategies to educate all family planning providers about new policies

• Help develop strategies to educate women and men in Medicaid so they can take advantage of family planning services

• Educate women not eligible for Medicaid, but were in IHW Waiver, to apply for health insurance during open enrollment periods