Collaborative Research to Document the Impact of Reimbursement Changes on Access to Long-Acting, Reversible Contraception

Contraceptive choice, access, and affordability are core determinants of an individuals’ economic and personal health. Access to contraceptives has improved women’s rates of enrollment and graduation from higher education, contributed to significant increases in women’s participation in the workforce, and is connected to increased wages.[i] Federally Qualified Health Centers (FQHCs) are community-based providers that exist to meet patients where they live and provide the primary care services they need. However, these health centers face unique reimbursement challenges to offering long-acting reversible contraceptives (LARCs) that may impede FQHC patients from accessing the full range of FDA-approved contraceptive methods.

Instead of being reimbursed for the cost of the service provided, FQHCs receive “bundled” payments for each qualifying visit or “encounter” under the Medicaid Prospective Payment System (PPS).[ii] While each FQHC’s PPS reimbursement rate is ostensibly derived from the cost of services for a generalized population, these payment rates often fall short of covering the costs associated with purchasing and stocking LARCs and providing related services. If FQHCs do not receive adequate reimbursement, these clinics may not be able to provide LARC services. One option to addressing this type of access barrier to LARCs is to unbundle, or “carve out”, the cost of the LARC device from the Medicaid PPS rate. In some states, LARC insertion and removal is also reimbursed separately from the PPS, depending on provider type.[1]

Medicines360 collaborated with Health Management Associates (HMA) and Waxman Strategies to conduct research focused on using an unbundling reimbursement strategy to expand access to LARCs in FQHCs. Several states have already used this strategy to increase LARC uptake. The research — which included interviews with providers, administrators, and stakeholders over the course of 2020 and early 2021 — concluded with the issuance of a policy brief for use by states interested in exploring a similar Medicaid reimbursement policy change. To illustrate an example of how one state unbundled LARCs, we gathered information resulting in a case study that details Georgia Medicaid program’s experience implementing a LARC unbundling policy.

Policy Brief: The Policy Brief describes the different Medicaid reimbursement policy options for expanding access to LARC at FQHCs.  The Policy Brief recommends that interested policymakers pursue one of the following options:

  1. Pursue a Medicaid state plan amendment (SPA) that allows FQHCs to unbundle reimbursement of the LARC device from the PPS rate as a medical benefit; or
  2. Use an FQHC alternative payment methodology (APM) as defined in statute, either in place of or alongside the PPS rate, that incorporates family planning incentives and/or performance metrics as part of a broader payment methodology.

The Policy Brief also recommends that policymakers include both insertion and removal service fees as part of this policy to make sure provider incentives are aligned with a patient’s autonomy and choice in use of LARC methods.

Georgia Case Study: In 2010, 60 percent of all pregnancies in Georgia (119,000) were unintended.[iii]  Unintended or closely spaced pregnancies can have negative health and economic consequences for women and their families.[iv] The LARC unbundling policy for FQHCs and Rural Health Clinics (RHCs) was one component of Georgia Medicaid’s strategy to address these outcomes. In 2015, the Georgia Medicaid program, with involvement of the Georgia Primary Care Association (PCA), submitted and received approval for a SPA that expanded the unbundling of reimbursement for LARC devices from the PPS at FQHCs and RHCs within fee-for-service (FFS) Medicaid.  The Georgia Medicaid FFS data for the period following the unbundling policy change shows that the percentage of FQHC/RHC services that were LARC encounters gradually increased through 2018 and does correlate with the timing of the LARC FQHC unbundling policy. The claims data show the rate of increase was most prominent in 2015 and 2016: 36.8 percent in 2015 and 23.5 percent in 2016. In Georgia, the unbundling policy change may be contributing to improvement in the outcomes that Georgia Medicaid sought to address, as well as on contraceptive access and availability. Data from the Georgia Pregnancy Risk Assessment Monitoring System (PRAMS) shows that unintended pregnancies were down from 60 percent in 2010 to 43.3 percent in 2017.[v]

To learn more about the research methodology, findings, policy recommendations, the full documents are accessible on the Waxman Strategies and Health Management Associates (HMA) websites.

Medicines360 conducted this research in collaboration with HMA and Waxman Strategies with support from Arnold Ventures. Medicines360 is a nonprofit global pharmaceutical company focused on expanding healthcare access for women and is the developer of the LARC product, LILETTA®.

[1] For example, Georgia Medicaid provides separate FFS reimbursement to hospital-based Rural Health Center providers for LARC insertion and removal.

[i] Anna Bernstein, et al., The Effects of Contraceptive Access: A Review of the Evidence, Institute for Women’s Policy Research (Jul. 2020), available at https://iwpr.org/wp-content/uploads/2020/07/B381_Contraception-Access_Final.pdf.

[ii] Note that the PPS system only applies to fee-for-services Medicaid patients.

[iii] Kathryn Kost, Unintended Pregnancy Rates at the State Level: Estimates for 2010 and Trends Since 2002, Guttmacher Institute

(Jan. 2015), available at http://www.guttmacher.org/pubs/StateUP10.pdf.

[iv] Amy Tsui, et al., Family Planning and the Burden of Unintended Pregnancies, National Institutes of Health (Jun. 2010), available at

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115338/.

[v] See, Georgia PRAMS, available at https://dph.georgia.gov/PRAMS.

About Medicines360

Medicines360, located in San Francisco, California, is a nonprofit global women’s health pharmaceutical organization with a mission to catalyze equitable access to medicines and devices through product development, policy advocacy, and collaboration with global and US partners. Medicines360, through its subsidiary Impact RH360, launched the Avibela Project to expand access to hormonal IUDs in low- and middle-income countries. For more information, visit medicines360.org

Share This

AVIBELA can be made available in the following 88 countries

  1. Algeria
  2. Angola
  3. Bangladesh
  4. Belize
  5. Benin
  6. Bhutan
  7. Botswana
  8. Burkina Faso
  9. Burundi
  10. Cambodia
  11. Cameroon
  12. Cape Verde
  13. Central African Republic
  14. Chad
  15. Comoros
  16. Costa Rica
  17. Cuba
  18. Democratic Republic of the Congo
  19. Djibouti
  20. Dominica
  21. Dominican Republic
  22. Egypt
  23. El Salvador
  24. Equatorial Guinea
  25. Eritrea
  26. Ethiopia
  27. Gabon
  28. Ghana
  29. Grenada
  30. Guatemala
  31. Guinea
  32. Guinea-Bissau
  33. Haiti
  34. Honduras
  35. India
  36. Indonesia
  37. Ivory Coast
  38. Jamaica
  39. Kenya
  40. Lao PDR
  41. Lesotho
  42. Liberia
  43. Libya
  44. Madagascar
  45. Malawi
  46. Malaysia
  47. Maldives
  48. Mali
  49. Mauritania
  50. Mauritius
  51. Mayotte
  52. Morocco
  53. Mozambique
  54. Myanmar
  55. Namibia
  56. Nepal
  57. Nicaragua
  58. Niger
  59. Nigeria
  60. Pakistan
  61. Panama
  62. Papua New Guinea
  63. Philippines
  64. Republic of the Congo
  65. Rwanda
  66. Sao Tome and Principe
  67. Senegal
  68. Seychelles
  69. Sierra Leone
  70. Somalia
  71. South Africa
  72. South Sudan
  73. Sri Lanka
  74. Kitts and Nevis
  75. Lucia
  76. Vincent & the Grenadines
  77. Sudan
  78. Swaziland
  79. Tanzania
  80. Thailand
  81. The Gambia
  82. Timor-Leste
  83. Togo
  84. Tunisia
  85. Uganda
  86. Vietnam
  87. Zambia
  88. Sri Lanka

Tina Raine-Bennett, MD, MPH, FACOG

Chief Executive Officer

Tina Raine-Bennett, MD, MPH, is CEO of Medicines360. Previously, she served as a senior research scientist at the Kaiser Permanente Northern California Division of Research and the research director of the Women’s Health Research Institute. She is a Board-Certified Obstetrician Gynecologist who received her medical training at the University of California, San Diego, and post-graduate residency training and MPH at the University of Washington in Seattle, where she also completed a Robert Wood Johnson Clinical Scholars Fellowship. She was also senior staff physician at Kaiser Permanente and has a special interest in family planning and adolescent reproductive health.

As the director of the Women’s Health Research Institute, Dr. Raine-Bennett focused on expanding research on women’s health within the Division and translating women’s health research into clinical practice and policy within the Ob/Gyn departments in Northern California. She also promoted the involvement of clinicians in research designed to improve the health outcomes and healthcare experiences of women at Kaiser Permanente and women in general.

Prior to Kaiser Permanente, Dr. Raine-Bennett was a professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at University of California, San Francisco (UCSF). She was based at San Francisco General Hospital where she was also the medical director of the New Generation Health Center, a UCSF affiliate site that provides community-based reproductive health services. Dr. Raine-Bennett’s research has focused on contraceptive methods and on elucidating factors that influence contraceptive choice and continuation, and she was principal investigator on NIH grants to assess hormonal contraceptive use predictors and develop interventions to improve contraceptive access.

Her past and current research on emergency contraception has focused on the safety of making emergency contraception more accessible and she conducted a pivotal clinical trial to make emergency contraception available to teens without a prescription. She served on the editorial board of Obstetrics and Gynecology and has over 100 peer-reviewed publications. She was the Treasurer of the Board of Directors for the Society of Family Planning and Society of Family Planning Research Fund. She has also served as an examiner for the American Board of Obstetrics and Gynecology, and on national committees for the American College of Obstetrics and Gynecology and the National Medical Board of Planned Parenthood Federation of America.