Since 1972, states have been required to provide family planning services in their Medicaid programs. Now, under the Affordable Care Act, states have the option to offer such services (PDF, 175.39 KB), under the authority of the state plan, to people who would not otherwise be eligible for Medicaid. This has greatly expanded the number of people who can benefit from these essential services. In addition, some states have not adopted protocols that facilitate the prevention of STIs and HIV, such as accelerated couples therapy or PrEP coverage without prior authorization, important public health advances that have the potential to improve the sexual health of high-risk populations.
States can decide what services they cover under these limited-scope family planning programs, and pharmacy coverage under limited-scope family planning programs is restricted to family planning and related services. If you're eligible for FPBP, you'll get a Common Benefit Identification Card (CBIC), if you don't already have one, which you'll need to use every time you need covered family planning services. Medicaid is the primary source of funding for family planning services for low-income people and is jointly funded and managed by the federal and state governments. States were asked primarily about coverage of traditional Medicaid services and if they aligned coverage policies in limited-scope family planning programs and Medicaid expansions, where appropriate.
Screening for cervical and breast cancer during a family planning visit is considered appropriate. States have considerable discretion regarding Medicaid eligibility criteria, managed care enrollment, and payment structures that also affect beneficiary coverage and access to family planning care, as well as the amount, duration, and scope of covered services. If a condition is discovered that requires treatment during an evaluation, the state must provide the services necessary to treat that condition, regardless of whether those services are included in the state Medicaid plan or not. All responding states cover screening mammograms for eligible individuals through the traditional Medicaid pathway, and most cover genetic screening (BRCA) and counseling, as well as medications to prevent or reduce the risk of breast cancer for women at higher risk.
The list of preventive services recommended by these committees includes several family planning and related services, specifically contraceptives approved, authorized and approved by the FDA with a prescription, STI and HIV screening, cervical and breast cancer screening, HPV vaccine, HIV testing, healthy woman visits and screenings for intimate partner violence. Federal Medicaid law classifies family planning services and supplies as a “category of mandatory benefits” that states must cover, but it does not formally define the specific services that should be included, giving states discretion as to what services they include in this category. The federal Medicaid statute sets minimum federal standards and, for decades, has classified family planning as a category of mandatory benefits that all state programs must cover, but it does not define exactly what services should be included. However, few states reported covering accelerated couples therapy (EPT), which is supported by the CDC as an effective method of controlling the transmission of STIs.
Below are detailed survey results from 41 states and DC regarding limits on coverage and use of reversible contraceptives and permanent contraceptives, care for healthy women, STI and HIV services, breast and cervical cancer services, and requirements for managed care plans coverage of family planning services. Most states that responded to the survey have contracts with managed care organizations (MCOs) under a capitated structure to provide Medicaid services, including family planning. Prescription drug coverage is another important element of Medicaid coverage for family planning services. .