This page shows textual changes in the document between the two versions indicated in the dates above. Textual matter removed in the later version is indicated with red strikethrough and textual matter added in the later version is indicated with blue.
This report provides answers to frequently asked questions concerning the provision, funding, and coverage of reproductive health services. The report is organized by the federal program that pays for or directly provides these services. It concludes with questions about coverage requirements for reproductive health services under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), and discussions of various federal programs that provide grants to non-governmental entities to provide reproductive health services.
Reproductive health services are preventive, diagnostic, and treatment services related to the reproductive systems, functions, and processes of men and women. These include, but are not exclusive to, services related to contraception (family planning), sexually transmitted infections (STIs)/sexually transmitted diseases (STDs), and screening and treatment for cancers of the reproductive organs and the breast.1
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Types of Contraceptives, as Defined by the Food and Drug Administration 1. sterilization surgery for women; Source: FDA, "Birth Control Guide," http://www.fda.gov/downloads/ForConsumers/ByAudience/ForWomen/FreePublications/UCM356451.pdf . |
A contraceptive is a product or service intended to lower a woman's risk of becoming pregnant. Contraceptive products and services are evaluatedPrior to marketing in the United States, contraceptive products are reviewed by the Food and Drug Administration (FDA). FDA approves those products and services that demonstrate safety and effectiveness.
Federal funding or reimbursement, when provided for contraception, is generally limited to those products and services that are FDA-approved. Such products and services certain surgical procedures and those products that are FDA approved or cleared for marketing. Such products vary in type, and include drugs, medical devices, or combinations of the two, and surgical procedures. FDA.
For contraceptive drugs, FDA approves those products that demonstrate substantial evidence that the drug is safe and effective for the purpose in the new drug application.2 For high-risk (class III) contraceptive devices, FDA approves those products that demonstrate reasonable assurance of safety and effectiveness. For moderate-risk (class II) contraceptive devices, FDA clears those products that demonstrate substantial equivalence to a device already on the market (a predicate device).3 FDA's Office of Women's Health has identified 20 different types of contraceptives, shown in the text box at right.
Under federal law, federal funds are generally not available to pay for abortions, except in cases of rape, incest, or endangerment of a mother's life. This restriction is the result of statutory and legislative provisions like the Hyde Amendment, which has been added to the annual appropriations measure for the Department of Health and Human Services (HHS) since 1976. Similar provisions exist in the appropriations measures for foreign operations, the District of Columbia, the Treasury, and the Department of Justice. Other codified restrictions limit the use of funds made available to the Department of Defense (DOD) and, the Indian Health Service (IHS), and the Department of Veterans Affairs.
Although not subject to the ACA's requirements regarding coverage of women's preventive health services, TRICARE—the DOD-administered health insurance program for uniformed service personnel, retirees, and their family members24—covers a range of women's preventive health services, including breast and cervical cancer screening at no charge.35 (For more information on the Affordable Care Act's requirements, see "Federal Mandates for Private Insurance Coverage.")
With respect to breast cancer screening, TRICARE covers annual physical examinations for women beginning at age 40 and at a physician's discretion for women younger than 40 who are at high risk of developing breast cancer. TRICARE also covers annual mammograms for women beginning at age 40, or at age 30 for those at high risk of developing breast cancer.
With respect to cervical cancer screening, TRICARE covers Pap smear testing for women 18 years of age or older. The frequency of Pap smear testing may be at the discretion of the patient and clinician, but not less frequently than every three years. Human Papillomavirus (HPV) testing is covered as a cervical cancer screening only when performed in conjunction with a Pap smear, and only for women aged 30 and older.
Female members of the uniformed services on active duty typically receive these services directly from military treatment facilities. Family members and retirees may also receive services outside of military treatment facilities, typically from private sector providers.
Under the regulations at 32 C.F.R. §199.4(e)(3), TRICARE provides the following family planning benefits:
The family planning benefit does not include the following:
The National Defense Authorization Act for Fiscal Year 2016 (P.L. 114-92) requires the Secretary of Defense to establish and disseminate clinical guidelines on contraception and contraception counseling as well as to make contraceptive counseling available to women members of the Armed Forces.8
Does the DOD Provide Abortions or Abortion Counseling?Under 10 U.S.C. §1093, the medical facilities and funds available to the DOD may not be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term, or in a case in which the pregnancy is the result of an act of rape or incest. TRICARE also covers medical and/or mental health services related to the covered abortion.
Abortion counseling, referral, preparation, and follow-up for a non-covered abortion are not eligible for reimbursement. Drugs such as Mifeprex and misoprostol may be cost-shared when the pregnancy is the result of an act of rape or incest.5
The VA uniform "medical benefits package" (codified at Title 38 C.F.R. §17.38)9 provides reproductive health services, such as routine physical exams, cervical cancer screening, evaluation and treatment of vaginal infections, pelvic pain and abnormal uterine bleeding, treatment of erectile dysfunction, reproductive mental health, and sexually transmitted disease (STD) screening, among other services, to eligible veterans who are enrolled in VA's health care system.10 Female Veterans Male Veterans Genetic counseling and testing Evaluation of erectile dysfunction Hysterosalpingogram (HSG) Genetic counseling and testing Infertility counseling Infertility counseling Laboratory blood testing (e.g. Follicle-stimulating hormone (FSH); luteinizing hormone (LH)) Seman analysis Saline infused Sonohysterogram Transrectal and/or scrotal ultrasonography Source: Department of Veterans Affairs, Veterans Health Administration, Infertility and Assisted Reproductive Technologies, Fact Sheet, January 2015. Notes: This is not an exhaustive list of all the test and procedures. Female Veterans Male Veterans Hormonal therapies (Controlled ovarian hyper-stimulation) Hormonal therapies (e.g., clomiphene citrate, human chorionic gonadotropin (HCG) phosphodiesterase 5 (PDE5) medications, testosterone) Intrauterine insemination (IUI), also known as artificial insemination (AI) Sperm cryopreservation for medically indicated conditions Reversal of tubal ligation (Tubal Reanastomosis) Surgical correction of structural pathology (i.e., varicocelectomy, Peyronie's Repair, among others) Surgical correction of structural pathology consistent with standard of care including operative laparoscopy and operative hysteroscopy Vasectomy reversal (vasectomy, varicocelectomy, vasovasostomy) Source: Department of Veterans Affairs, Veterans Health Administration, Infertility and Assisted Reproductive Technologies, Fact Sheet, January 2015. Notes: This is not an exhaustive list of all the infertility related medical procedures.The VA provides reproductive health services to eligible veterans enrolled in the VA health care system, as provided in the VA's uniform "medical benefits package" currently codified at Title 38 C.F.R. §17.38.6 However, the medical benefits package does not include (1) abortions and abortion counseling or (2) in vitro fertilization (IVF).7 TRICARE does not cover (1) services and supplies related to a non-covered abortion, (2) counseling, referral, preparation and follow-up for a non-covered abortion, and (3) abortions for fetal abnormality or for psychological reasons.
Department of Veterans Affairs (VA)
Does the VA Provide Reproductive Health Services?
Furthermore, with the VA's decision to exclude abortions, as required by the Veterans Health Care Act of 1992 (P.L. 102-585), from the medical benefits package, the VA also made a decision to no longer perform therapeutic abortions. Therefore (i.e., abortions that are performed in instances when needed to save the life of a mother). As a consequence of this, abortifacients such as RU 486 (mifepristone) are not available through VA pharmacies.8
The Indian Health Service provides health care directly or provides funds for Indian Tribes or Tribal Organizations to operate health care facilities. The IHS does not provide a standard medical benefit that includes or excludes certain services. Instead, services available vary by facility, and some facilities may provide reproductive health services.917 Among other services, the IHS reports that it provides specific women's health services such as mammograms and prenatal careother preventive screenings. The IHS also funds or operates programs to screen individuals at risk of HIV/AIDS and provide treatment services as necessary.10
The IHS is prohibited from using any of its appropriated funds to perform or pay for abortion services.11
Like other federal programs, Medicaid is subject to the Hyde Amendment. (See "Can Federal Funds Be Used to Pay for Abortions?")12 Medicaid program guidance further specifies that the Hyde Amendment does not prohibit a "state, locality, entity, or private person" from paying for abortion services, nor does it prohibit managed care providers from offering abortion coverage or impact a state's or locality's ability to contract with a managed care provider for such coverage with state-only funds (as long as such funds are not the state share of Medicaid matching funds).13,14
Through program regulations,15 and later revised through program guidance, Medicaid enrollees and providers may be required to comply with reasonable documentation requirements to assure that the abortion meets the Hyde amendment criteria. However, such documentation requirements may not prevent or impede coverage for abortions and may be waived if the treating physician certifies that the patient was unable to comply.16
An ectopic pregnancy is a pregnancy that occurs outside the womb (uterus). It is life-threatening to the mother.17 Medicaid federal financial participation (FFP) is available for medical procedures necessary for the termination of an ectopic pregnancy.18
Medicaid federal financial participation (FFP) is available for mifepristone only when its use is consistent with the Hyde Amendment restrictions (i.e., that limit federal funds to pay for abortions, except in cases of rape, incest, or endangerment of the mother's life). However, states must comply with state laws that set limitations on its use (e.g., requirements regarding parental notification and informed consent).19
The IHS provides emergency contraception (Plan B One-Step®, [Levonorgestrel] emergency contraception [EC] pill) through its pharmacies, emergency departments, and health clinics. In June 2013, the FDA approved Plan B One Step as an over-the-counter drug. This presented a challenge for IHS in making the drug available to its beneficiaries, given that the agency generally does not dispense drugs without a provider order to do so.19 In October of 2015, IHS amended its internal policies to make emergency contraception available without a provider visit or a need for the patient to register with the facility.20
Does the IHS Provide Abortions?The IHS is prohibited from using any of its appropriated funds to perform or pay for abortion services.21 IHS funds may be used in cases used where the life of the mother would be endangered if the fetus were carried to term, or in a case in which the pregnancy is the result of an act of rape or incest. IHS has developed and implemented protocols for its physicians to determine and certify cases when an abortion could be paid for because the IHS physician has determined that the mother's health would be endangered were the fetus to be carried to term.22 IHS will also provide health services necessary to terminate an ectopic pregnancy23—a pregnancy that occurs outside the womb (uterus), which is life-threatening to the mother.24
MedicaidStates are required to provide family planning services and supplies to Medicaid-eligible "individuals of child-bearing age (including minors who can be considered to be sexually active) and who desire such services and supplies."2025 States are permitted to provide targeted family planning services under Medicaid for populations who are not otherwise eligible for traditional Medicaid (e.g., nonpregnant, non-disabled childless adults) through special waivers of federal law.2126 Finally, the ACA established a new optional Medicaid eligibility group for family planning services so that states would no longer have to rely on time limited waiver authority to extend limited benefit coverage for family planning services and supplies to targeted eligibility groups (including groups who were not traditionally eligible for Medicaid). The ACA family planning eligibility group includes individuals (men and women) (1) who are not pregnant and (2) whose income does not exceed the highest income eligibility level established by the state for pregnant women.2227 Benefits for this new eligibility group are limited to family planning services and supplies and related medical diagnosis and treatment services.2328 In all cases, states are not permitted to charge cost-sharing for Medicaid family planning services and supplies.
States have discretion in identifying the specific services and supplies (including emergency contraception) covered under the traditional Medicaid state plan.2430 Family planning services and supplies include items and procedures for family planning purposes (i.e., contraceptive care31), as well as medical diagnosis and treatment services provided pursuant to a family planning service in a family planning setting (e.g., health education and promotion, and testing and treatment for sexually transmitted infections).2532 Medicaid programs may also cover sterilization services; however, federal law requires states to impose a minimum of a 30-day waiting period between the date the individual provides informed consent and the date of the procedure.26
As an alternative to traditional state plan services, states may offer alternative benefit plans (ABPs).27ABPs.35 ABPs must cover at least the 10 essential health benefits (EHBs).2836 In addition, ABP coverage must comply with the federal requirements for mental health parity, and special rules apply with regard to prescription drugs, rehabilitative and habilitative services and devices, and preventive care. The special rules for preventive care require coverage of a number of reproductive health care services for women, including well-woman visits, contraception, and breast and cervical cancer screening, as well as sexually transmitted disease screening for women and men, among other services. (The preventive services that must be covered are discussed later in this report inbelow in the subsection "What Types of Services Must Be Covered?" in the section on ""Federal Mandates for Private Insurance Coverage.") Among other requirements, ABPs.") ABP plans must also cover family planning services and supplies, among other requirements.29
The Medicaid program distinguishes between items and procedures for family planning purposes (i.e., contraceptive care), and family planning-related services (i.e., services provided in a family planning setting as part of or as follow-up to a family planning visit) to determine the federal medical assistance percentage (FMAP) rate available. Specifically, states may receive a 90% FMAP rate for items and procedures for family planning purposes.3040 By contrast, family planning-related services are reimbursable at the state's regular FMAP rate.3141 Family planning-related services are generally provided because they were identified, or diagnosed, during a family planning visit. Such services may include the following:32
Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as long-term services and supports (LTSS), to a diverse low-income population. Like other HHS programs, Medicaid is subject to the Hyde Amendment (see "Can Federal Funds Be Used to Pay for Abortions?").43 Medicaid program guidance further specifies that the Hyde Amendment does not prohibit a "state, locality, entity, or private person" from paying for abortion services, nor does it prohibit managed care providers from offering abortion coverage or affect a state's or locality's ability to contract with a managed care provider for such coverage with state-only funds (as long as such funds are not the state share of Medicaid matching funds).44,45 (Also see "Does Medicaid Cover Mifepristone (Mifeprex or RU-486)?") Through program regulations,46 and later revised through program guidance, Medicaid enrollees and providers may be required to comply with reasonable documentation requirements to ensure that the abortion meets the Hyde amendment criteria and is eligible for Medicaid federal financial participation (FFP). However, such documentation requirements may not prevent or impede coverage for abortions and may be waived if the treating physician certifies that the patient was unable to comply.47 Medicaid federal financial participation (FFP) is available for mifepristone only when its use is consistent with the Hyde Amendment restrictions (i.e., that limit federal funds to pay for abortions, except in cases of rape, incest, or endangerment of the mother's life). However, states must comply with state laws that set limitations on its use (e.g., requirements regarding parental notification and informed consent) regardless of the funding source.48 An ectopic pregnancy is a pregnancy that occurs outside the womb (uterus). It is life-threatening to the mother.49 Medicaid federal financial participation (FFP) is available for medical procedures necessary for the termination of an ectopic pregnancy.50 Under traditional Medicaid, states cover a wide array of mandatory services (e.g., inpatient hospital care, lab and x-ray services, pregnancy-related services and physician care). In addition, states may provide optional services (e.g., personal care services, prescription drugs, preventive services, clinic services, and infertility treatments). A number of these services can be used to meet a person's reproductive health needs. As discussed more fully below (see "What Types of Contraceptive Services and Supplies Does Medicaid Cover?") coverage of family planning services and supplies is a required Medicaid service. Medicaid enrollees receive reproductive health care from a range of Medicaid providers, including private physicians, federally qualified health centers, family planning clinics, health departments, and other clinics,33 and a majority (77%) of Medicaid women of childbearing age access care through some type of managed care arrangement.34 In general, under Medicaid's "freedom of choice of provider" requirement, states must permit enrollees to receive services from any willing Medicaid-participating provider,35 and states cannot exclude providers solely on the basis of the range of services they provide.36
Does Medicaid Cover Abortion Services?
Medicaid managed-care enrollees may be restricted to providers in the plan's network, except in the case of family planning services. For family planning services, Medicaid enrollees (regardless of whether they receive services through the managed care delivery system or not) may obtain family planning services from the provider of their choice (as long as the provider participates in the Medicaid program), even if they are not considered "in-network" providers.3758
The majority of Medicare beneficiaries are 65 years old or older. However, almost 1 million women aged 18 to 44more than 900,000 women under age 45 (i.e., of reproductive age) were eligible for Medicare in 20112013, as a result of disability.3960 Many reproductive health services are recommended for Medicare beneficiaries who are older than childbearing age. (Examples include breast and gynecological exams for women, and sexually transmitted infections screening and treatment for men and women.) As a result, any type of reproductive health service may be sought or advised for at least some Medicare beneficiaries.
There is no explicit statutory requirement for Medicare to cover contraceptive services or supplies for its enrollees. Women Medicare beneficiaries may get coverage of oral contraceptives through Medicare Part D prescription drug coverage. These and other forms of contraception may be covered to varying extents under Medicare Advantage plans, which are health plans offered by private companies that contract with Medicare to provide benefits.
Male or female sterilization (e.g., tubal ligation, vasectomy) is covered only where it is a necessary part of the treatment of an illness or injury. (For example, removal of reproductive organs may be required to treat cancers of those organs.) Sterilization is not covered as an elective procedure or for the sole purpose of preventing any effects of a future pregnancy.40
For individuals who are dually eligible for Medicare and Medicaid, Medicare is the primary payer. Medicaid pays for any additional services that it covers, and Medicare does not, after Medicare denies payment. For example, many contraceptive products and services for those dually eligible may be paid through the more generous Medicaid benefits for these supplies and services.41
Medicare Part B covers a number of preventive services that involve reproductive health. These include, among others, annual wellness visits, breast cancer screening, screening pelvic exams, pap smears, screening for HIV and other sexually transmitted infections (STIs), and prostate cancer screening.4263 Cost-sharing is waived for most, but not all, of these preventive services.
In addition, Medicare Parts A or B typically cover diagnostic and treatment services furnished by a certified provider. (Cost sharing typically applies.) Such reproductive health services include diagnosis and treatment of STIs and urinary tract infections, and management of precancerous and cancerous gynecological abnormalities.
Abortions are not covered Medicare procedures except (1) if the pregnancy is the result of an act of rape or incest or (2) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.43
Enacted in 1970 as Title X of the Public Health Service Act, the Family Planning Program provides grants to public and nonprofit agencies for family planning services, research, and training. Administered by HHS, it is the only domestic federal program devoted solely to family planning and related preventive health services. 65
Title X grants are awarded to a variety of entities, including state, local, and territorial health departments; hospitals; non-profit community health agencies; Planned Parenthood Federation of America affiliates; and family planning councils.66 Title X grantees can provide family planning services directly or they can delegate Title X monies to other entities to provide services. In 2014, Title X provided services to 4.1 million clients through more than 4,000 service sites located in the 50 states, the District of Columbia, and the U.S. territories and Freely Associated States.67
What Contraceptive Services Do Title X Projects Provide?Title X family planning services grants fund family planning and related preventive health services, such as contraceptive services. Title X regulations require funded projects to "provide a broad range of acceptable and effective medically approved family planning methods (including natural family planning methods) and services (including infertility services and services for adolescents)."68 Title X clinical guidelines advise providers that "contraceptive services should include consideration of a full range of FDA-approved contraceptive methods, a brief assessment to identify the contraceptive methods that are safe for the client, contraceptive counseling to help a client choose a method of contraception and use it correctly and consistently, and provision of one or more selected contraceptive method(s), preferably on site, but by referral if necessary."69 Title X contraceptive services offered to males include condoms, education and counseling, and, in some cases, vasectomy services.70
Title X projects are required to provide services free of charge for individuals under 100% of the federal poverty level, and to provide sliding scale fees for individuals between 100% and 250% of the federal poverty level. For unemancipated minors who request confidential services, eligibility for discounts is based on the minor's own income.71
Do Title X Projects Provide Emergency Contraception?Title X clinical guidelines advise providers that they "may inform clients about the availability of emergency contraceptive pills and may provide clients an advance supply of emergency contraceptive pills on-site or by prescription, if requested."72 One survey found that 87% of Title X sites had provided emergency contraception onsite in the previous three months.73
What Reproductive Health Services Do Title X Projects Provide?Title X family planning services grants fund family planning and related preventive health services, including reproductive health services such as breast and cervical cancer screening and prevention; sexually transmitted disease (STD) and HIV prevention education, counseling, testing, and referral; preconception health services; and counseling on establishing a reproductive life plan. Title X provides services to men and women. Services offered to men include education and counseling, STD testing and treatment, and HIV testing.74
Title X projects are required to provide services free of charge for individuals under 100% of the federal poverty level, and to provide sliding scale fees for individuals between 100% and 250% of the federal poverty level. For unemancipated minors who request confidential services, eligibility for discounts is based on the minor's own income.75
Does the Title X Family Planning Program Fund Abortions?By law, Title X funds may not be used for abortions.76 The prohibition on abortion does not apply to all the activities of a Title X grantee, but only to activities that are within the Title X project. The grantee's abortion activities must be "separate and distinct" from the Title X project activities.77
Program regulations require Title X projects to offer pregnant women information and counseling on each of the following options: prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination. If the woman requests such information and counseling, the project must give "neutral, factual information and nondirective counseling on each of the options, and referral upon request, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling."78 What Legislative Mandates Apply to the Use of Title X funds?The Consolidated Appropriations Act, 2016 (P.L. 114-113), which provided full year funding for FY2016, continues requirements on the use of Title X funds included in previous years' appropriations laws:
The above requirements are in addition to statutory mandates in Title X of the Public Health Service Act, which, among other things, require family planning participation to be voluntary and prohibit the use of Title X funds in programs in which abortion is a method of family planning.
The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) established private insurance coverage requirements for a variety of health services, including many reproductive health services. Although these requirements do not directly involve federal spending, they affect coverage, and thereby spending, in the private health insurance market.
All non-grandfathered private health insurance plans offered in the nongroup, small-group, and large-group markets4479 are required to cover, without cost sharing, a specified set of preventive health services.4580 Many of these are reproductive health services, including, among others, (1) screening and counseling for sexually transmitted infections (STIs); (2) universal HIV screening; (3) breast cancer screening, genetic testing, and preventive medications such as Tamoxifen, when indicated; (4) gynecological exams and pap smears; (5) well-woman visits; (6) a variety of prenatal care services; and (7) contraception.46
In addition, the ACA requires all non-grandfathered private insurancehealth plans offered in the nongroup and small-group markets (both inside and outside exchanges) must offer the essential health benefits (EHB), a group of 10 broad categories of benefits. Generally, coverage in these categories must be equal in scope to a typical employer health plan. Each state has an EHB-benchmark plan that serves as a reference plan for that state. Nongroupin the non-group and small-group private health insurance markets to offer a core package of health care services, known as the essential health benefits (EHB). The ACA does not specifically define this core package but rather lists 10 benefit categories from which benefits and services must be included. For the 2014-2017 coverage years, each state was required to select an EHB-benchmark plan. The benchmark plan serves as a reference plan on which non-group and small-group market plans must substantially base their benefits package on the benchmark plan for that state.47packages. 82 The EHB category "preventive and wellness services and chronic disease management" is an exception. By regulation, all EHB plans must cover, without cost-sharing, the same specified set of preventive health services described in the previous paragraph.4883 Additional services in this EHB category (such as chronic disease management) and reproductive health services in other EHB categories (such as maternity care) would be covered according to state benchmark plans.
In general, the ACA requires group health plans and health insurance issuers, unless grandfathered, to cover contraception. In May 2015, the Administration issued guidance specifying the types of contraceptives that must be covered, namely 18 types of contraception for women listed in the FDA Birth Control Guide.4984 (See "What Are Contraceptive Services?") Because the guidance derives from a requirement in the ACA to cover women's preventive services, male sterilization and male condoms are excluded from the coverage requirement.50
The ACA's implementing regulations essentially provide an exemption to the contraceptive coverage requirement for churches and similar religious orders, and an accommodation for certain other employers with religious objections.5186 Under the accommodation, a third-party plan administrator is responsible for administering and paying for contraceptive benefits.52 Challenges87 Since ACA's enactment, challenges to the accommodation as a violation of religious freedom continue to work their way through the courts.
Federal health care payment and health service delivery programs (e.g., Medicare and Medicaid, the VA, Tricare, and IHS) will cover or directly provide certain reproductive health services. In addition, the federal government provides Title X program is the one program that provides dedicated support for non-governmental entities to provide reproductive health-related services to low-income populations. Below are some selected examples:
Author Contact Information
Acknowledgments
[author name scrubbed], Specialist in Health Care Financing,; [author name scrubbed], Specialist in Biomedical Policy; and [author name scrubbed], Information Research SpecialistAnalyst in Health Care Financing, provided valuable comments on drafts of this report.
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Adapted by Congressional Research Service from the Association of Reproductive Health Professionals, Position Statements, https://www.arhp.org/about-us/position-statements. |
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For more information on FDA drug regulation, see CRS Report R41983, How FDA Approves Drugs and Regulates Their Safety and Effectiveness |
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CRS Report RL33537, Military Medical Care: Questions and Answers, by [author name scrubbed]. |
Department of Defense, TRICARE Policy Manual, Chapter | |||||||||||||||||||||||||
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Department of Defense, TRICARE Policy Manual, Chapter 4, |
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For additional information, please see page 35 of CRS Report R44120, FY2016 National Defense Authorization Act: Selected Military Personnel Issues, coordinated |
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Department of Veterans Affairs, Veterans Health Administration, |
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Ibid. p. 20.
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The Health Care Services for Women Act, November 4, 1992, P.L. 102-585, Title I, §106, 106 Stat. 4847, provided: "(a) General authority. In furnishing hospital care and medical services under chapter 17 of title 38, United States Code [38 USCS §§1701 et seq.], the Secretary of Veterans Affairs may provide to women the following health care services: "(1) Papanicolaou tests (pap smears). "(2) Breast examinations and mammography. "(3) General reproductive health care, including the management of menopause, but not including under this section infertility services, abortions[emphasis added], or pregnancy care (including prenatal and delivery care), except for such care relating to a pregnancy that is complicated or in which the risks of complication are increased by a service-connected condition." Veterans' Health Care Eligibility Reform Act of 1996 (P.L. 104-262), required VA to establish and implement a national enrollment system and soon thereafter VA established through regulations a Uniform Medical Benefits package. VA's Uniform Medical Benefits package included pregnancy and delivery services as authorized by law and certain medically necessary infertility services. See Title 38 Code of Federal regulations (C.F.R) Sections 17.38(a)(1)(xiii) and 17.38(b) [care needed to promote, preserve, or restore health]. Abortions, abortion counseling, and in-vitro fertilization (IVF) were expressly excluded from the medical benefits package. See Title38 C.F.R, Section17.38(c)(1) & (2). 16.
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Department of Veterans Affairs, Veterans Health Administration, "Health Care Services For Women Veterans," VHA Handbook 1330.01, May 21, 2010. 17.
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CRS Report R43330, The Indian Health Service (IHS): An Overview, by [author name scrubbed]. 18.
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U.S. Department of Health and Human Services (HHS), Indian Health Service (IHS), Fiscal Year 2017 Indian Health Service Justification of Estimates, https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY2017CongressionalJustification.pdf. 19.
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See, for example, Mary Annette Pember, "Emergency Contraception Finally Available Through All IHS Facilities," Indian Country, October 19, 2015, http://indiancountrytodaymedianetwork.com/2015/10/19/emergency-contraception-finally-available-through-all-ihs-facilities-162134. 20.
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U.S. Department of Health and Human Services (HHS), Indian Health Service (IHS), Indian Health Manual: Part 1- General, Chapter 15-Emergency Contraception," https://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p1c15. 21.
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25 U.S.C. §1676. 22.
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U.S. Department of Health and Human Services (HHS), Indian Health Service (IHS), Indian Health Manual: Part 1- General, Chapter 13-Maternal and Child Health" https://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p3c13#3-13.14. 23.
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U.S. Department of Health and Human Services (HHS), Indian Health Service (IHS), Indian Health Manual: Part 1- General, Chapter 13-Maternal and Child Health" https://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p3c13#3-13.14. 24.
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National Institutes of Health, National Library of Medicine, MedlinePlus Medical Encyclopedia, http://www.nlm.nih.gov/medlineplus/encyclopedia.html. |
In FY2014, states claimed federal financial participation (FFP) for 118 abortions: 64 were due to endangerment to the life of the mother, 52 were due to rape, and 2 were due to incest. Department of Health and Human Services, Office of the Assistant Secretary for Financial Resources, FY 2016 Moyer Material, February 15, 2015, p. 81. |
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Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Dear State Medicaid Director Letter, February 12, 1998, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf. |
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| 14. |
Although FFP is forbidden for most abortions, 17 state Medicaid programs fund all or most "medically necessary" abortions with state-only funds. Four states do so voluntarily, and 13 states do so pursuant to a court order. For more information, see Guttmacher Institute, State Policies in Brief, State Funding of Abortion Under Medicaid, July 1, 2015. http://www.guttmacher.org/statecenter/spibs/spib_SFAM.pdf |
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| 15. |
42 C.F.R. §441.203, 45 C.F.R. §74.20, 42 C.F.R. §441.208 and 42 C.F.R. §441.206. |
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| 16. |
Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Letter to Medicaid Directors, February 12, 1998, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf. |
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| 17. |
National Institutes of Health, National Library of Medicine, MedlinePlus Medical Encyclopedia, http://www.nlm.nih.gov/medlineplus/encyclopedia.html. |
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| 18. |
42 C.F.R. §441.207. |
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| 19. |
Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Letter to State Medicaid Directors, SMDL# 01-018, March 30, 2001, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd033001.pdf. |
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Section 1905(a)(4)(C) of the Social Security Act. In FY2010, Medicaid accounted for 75% of U.S. public family planning expenditures (including federal, state, and local government spending), according to Adam Sonfield and Rachel Benson Gold, "Public Funding for Family Planning, Sterilization and Abortion Services," FY1980-2010, Guttmacher Institute, March 2012, http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf. |
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Targeted family planning waivers may offer a limited set of services (i.e., family planning services and supplies and related services) to a specific population identified in the waiver special terms and conditions. These individuals may not be eligible for full Medicaid state plan services. |
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Section |
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Section 1902(ii)(1) of the Social Security Act. |
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30.
42 C.F.R. §447.56(a)(2)(ii) and 42 C.F.R. §438.108. |
For more on the range of benefits covered by states, see Usha Ranji, Yali Bair, and Alina Salganicoff, "Medicaid and Family Planning: Background and Implications of the ACA," Kaiser Family Foundation, July 8, 2015, http://kff.org/womens-health-policy/issue-brief/medicaid-and-family-planning-background-and-implications-of-the-aca/; and Kaiser Family Foundation and George Washington University Medical Center School of Public Health and Health Services, "State Medicaid Coverage of Family Planning Services: Summary of State Survey Findings," November 2009, http://kff.org/medicaid/state-medicaid-coverage-of-family-planning-services/. |
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32.
Beneficiaries must be permitted to choose the method of family planning they desire, and free from coercion or mental pressure when accessing family planning services (42 C.F.R. §441.20). |
Section 1905(a)(4)(C) of the Social Security Act. |
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42 C.F.R. §§441.253 through 441.256. |
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States that choose to implement the ACA Medicaid expansion are required to provide the individuals newly eligible for Medicaid through the expansion Medicaid services through ABPs (with exceptions for selected special-needs subgroups). States also have the option to provide ABP coverage to other subgroups. |
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|
|
36.
States that choose to implement the ACA Medicaid expansion are required to provide the individuals newly eligible for Medicaid through the expansion Medicaid services through ABPs (with exceptions for selected special-needs subgroups). States also have the option to provide ABP coverage to other subgroups. |
The 10 essential health benefits required under the ACA include (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6) prescribed drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. |
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For more information, see | ||||||||||||||||||||||||||||
| 30. |
Section 1903(a)(5) of the Social Security Act. |
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| 31. | In general, emergency contraception is available without a prescription for women over the age of 17. For more information on emergency contraception's availability over the counter, see Food and Drug Administration, "FDA Approves Plan B One-Step Emergency Contraceptive for Use Without a Prescription for All Women of Child-bearing Potential," press release, June 20, 2013, http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm358082.htm. Based on survey information, it appears as though some state Medicaid programs also cover non-prescription emergency contraception, for more information, see Princeton University, Office of Population Research & Association of Reproductive Health Professionals, The Emergency Contraception Website, available at http://ec.princeton.edu/info/Medicaid.html. Section 1903(a)(5) of the Social Security Act. |
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|
Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Center for Medicaid, CHIP and Survey & Certification, Letter to State Health Officials, RE: Family Planning Services Option and New Benefit Rules for Benchmark Plans, SMDL#10-013 ACA# 4, July 2, 2010 | ||||||||||||||||||||||||||||
| 43.
|
|
In FY2015, states claimed federal financial participation (FFP) for 153 abortions: 108 were due to endangerment to the life of the mother, 44 were due to rape, and 1 was due to incest. Department of Health and Human Services, Office of the Assistant Secretary for Financial Resources, FY 2017 Moyer Material, February 22, 2015, Addendum: Abortion-Related Reporting. 44.
|
|
Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Dear State Medicaid Director Letter, February 12, 1998, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf. 45.
|
|
Although FFP is forbidden for most abortions, 17 state Medicaid programs fund all or most "medically necessary" abortions with state-only funds. Four states do so voluntarily, and 13 states do so pursuant to a court order. For more information, see Guttmacher Institute, State Policies in Brief, State Funding of Abortion Under Medicaid, June 1, 2016. https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid. 46.
|
|
42 C.F.R. §441.203, 45 C.F.R. §74.20, 42 C.F.R. §441.208 and 42 C.F.R. §441.206. 47.
|
|
Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Letter to Medicaid Directors, February 12, 1998, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf. 48.
|
|
Department of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations, Letter to State Medicaid Directors, SMDL# 01-018, March 30, 2001, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd033001.pdf. 49.
|
|
National Institutes of Health, National Library of Medicine, MedlinePlus Medical Encyclopedia, http://www.nlm.nih.gov/medlineplus/encyclopedia.html. 50.
|
|
42 C.F.R. §441.207. 51.
|
|
States that choose to implement the ACA Medicaid expansion are required to provide the individuals newly eligible for Medicaid through the expansion Medicaid services through ABPs (with exceptions for selected special-needs subgroups). States also have the option to provide ABP coverage to other subgroups. 52.
|
|
The 10 essential health benefits required under the ACA include (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6) prescribed drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. |
A 2013 survey found that, among Medicaid-enrolled women aged 15-44 who had their most recent gynecological exam in the past three years, 57% received the service in a private physician's office or HMO, 13% from a community health center or public clinic, 5% from a family planning or Planned Parenthood clinic, and 5% from a school or college-based or urgent care/walk-in facility. The rest received the gynecological exam from other places or did not answer the question. Alina Salganicoff et al., "Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women's Health Survey," Kaiser Family Foundation, Washington, DC, May 2014, https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8590-women-and-health-care-in-the-early-years-of-the-affordable-care-act.pdf#page=33. |
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|
Usha Ranji, Yali Bair, and Alina Salganicoff, Medicaid and Family Planning: Background and Implications of the ACA, The Kaiser Family Foundation, Issue Brief, July 2015, http://files.kff.org/attachment/issue-brief-medicaid-and-family-planning-background-and-implications-of-the-aca. |
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Under federal law, Medicaid enrollees may obtain medical services "from any institution, agency, community pharmacy, or person, qualified to perform the service or services required ... who undertakes to provide him such services." This provision is often referred to as the "any willing provider" or "free choice of provider" provision. (Section 1902(a)(23) of the Social Security Act, 42 C.F.R. §431.51, see also Department of Health and Human Services, Center for Medicaid, CHIP and Survey & Certification, CMCS Informational Bulletin, Update on Medicaid/CHIP, June 1, 2011, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/6-1-11-Info-Bulletin.pdf.). |
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|
Sections 1902(a)(23) and 1932(a) of the Social Security Act and 42 C.F.R. §431.51. | ||||||||||||||||||||||||||||
| 37. |
Section 1902(e)(2). |
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| 57.
|
|
See Section 1902(a)(23)(B) of the Social Security Act; 42 C.F.R. §431.51(b)(1); and 42 C.F.R. Part 438. 58.
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|
Section 1902(e)(2) of the Social Security Act. |
Medicare benefits in general are summarized in CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed] |
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Data |
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64.
CMS, "Preventive Services," interactive chart for the Medicare Fee-for-Service Program, January 2015, http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf. |
CMS, Medicare National Coverage Determination for |
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CRS Report RL33644, Title X (Public Health Service Act) Family Planning Program, by [author name scrubbed]. 66.
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|
A full list of grantees is available at HHS, Office of Population Affairs, "Title X Family Planning Directory of Grantees," May 2016, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/title-x-grantees-list/title-x-directory-grantees.pdf. 67.
|
|
Christina Fowler, Julia Gable, Jiantong Wang, and Beth Lasater, Family Planning Annual Report: 2014 National Summary, RTI International, Research Triangle Park, NC, August 2015, pp. 7-8, http://www.hhs.gov/opa/pdfs/title-x-fpar-2014-national.pdf. A searchable directory of Title X providers is at HHS, Office of Population Affairs, Title X Grantees List, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/title-x-grantees-list/. 68.
|
|
42 C.F.R. §59.5(a)(1). The availability of specific contraceptive methods varies by site. 69.
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|
Title X clinical guidelines are laid out in Loretta Gavin, Susan Moskosky, Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm. See also HHS, Office of Population Affairs, Title X Family Planning Program Priorities, http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/program-priorities. 70.
|
|
Male Services, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/male-services. 71.
|
|
42 C.F.R. §59.2, §59.5. 72.
|
|
Loretta Gavin, Susan Moskosky, Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm. 73.
|
|
Marion W. Carter, Loretta Gavin, Lauren B. Zapata, et al., "Four aspects of the scope and quality of family planning services in US publicly funded health centers: Results from a survey of health center administrators," Table 2, Contraception, in press, available online April 25, 2016, http://dx.doi.org/10.1016/j.contraception.2016.04.009. The survey's respondents included 1,045 Title X sites. The survey was conducted June 2013 to May 2014, and reflects practices prior to the release of current Title X clinical guidelines in April 2014. Prior guidelines did not address advance provision of emergency contraception, but noted that "certain oral contraceptive regimens have been found by the Federal Food and Drug Administration to be safe and effective for use as postcoital emergency contraception when initiated within 72 hours after unprotected intercourse." U.S. Department of Health and Human Services, Office of Family Planning, Program Guidelines for Project Grants for Family Planning Services, January 2001, http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/program-guidelines/2001-ofp-guidelines-complete.html. 74.
|
|
42 C.F.R. §59.5. Title X clinical guidelines are laid out in Loretta Gavin, Susan Moskosky, Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm. See also HHS, Office of Population Affairs, Title X Family Planning Program Priorities, http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/program-priorities; Male Services, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/male-services. 75.
|
|
42 C.F.R. §59.2, §59.5. 76.
|
|
42 U.S.C. §300a-6. In addition, language in annual Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations bills have also prohibited the use of Title X funds for abortions. (In FY2016, this provision appeared in P.L. 114-113, Division H, Title II, 129 Stat. 2602.) 77.
|
|
HHS, Office of Population Affairs, "Provision of Abortion-Related Services in Family Planning Services Projects," 65 Federal Register 41281-41282, July 3, 2000, https://federalregister.gov/a/00-16759; and HHS, Office of Population Affairs, "Standards of Compliance for Abortion-Related Services in Family Planning Services Projects," 65 Federal Register 41270–41280, July 3, 2000, https://federalregister.gov/a/00-16758. 78.
|
|
42 C.F.R. §59.5(i). |
|
| 42. |
CMS, "Preventive Services," interactive chart for the Medicare Fee-for-Service Program, January 2015, http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf. |
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| 43. |
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For more information about private health insurance, see CRS Report RL32237, Health Insurance: A Primer, by [author name scrubbed] and [author name scrubbed] |
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45 C.F.R. §147.130, "Coverage of Preventive Health Services." |
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|
The preventive services that must be covered are listed in their entirety at Healthcare.gov, "Preventive Care Benefits," https://www.healthcare.gov/preventive-care-benefits/. Coverage is not required for services that are furnished out of network. 45 C.F.R. §147.130(a)(3). A final regulation clarifying coverage for services furnished out-of-network was published in July 14, 2015 (80 Federal Register 41318). |
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|
45 C.F.R. §156.115(a)(4), "Provision of EHB," by reference to 45 C.F.R. §147.130, "Coverage of Preventive Health Services." |
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|
Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury, "FAQs about Affordable Care Act Implementation, Part XXVI," May 11, 2015, http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html#Affordable%20Care%20Act. |
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Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury, "Coverage of Certain Preventive Services Under the Affordable Care Act, Final Rule" 80 Federal Register 41318, July 14, 2015. |
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|
CRS |
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|
Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury, "Coverage of Certain Preventive Services Under the Affordable Care Act, Final Rule" 80 Federal Register 41322 ff., July 14, 2015. |
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89CRS Legal Sidebar WSLG1579, No Answer for Now: Supreme Court Remands Nonprofit Contraceptive Coverage Challenges, by [author name scrubbed]. |
CRS Report RL33644, Title X (Public Health Service Act) Family Planning Program, by [author name scrubbed]. |
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| 54. |
A full list of grantees is available at HHS, Office of Population Affairs, "Title X Family Planning Directory of Grantees," June 2015, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/title-x-grantees-list/title-x-directory-grantees.pdf. |
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These facilities are also called federally qualified health centers (FQHCs) or community health centers. |
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|
CRS Report R43937, Federal Health Centers: An Overview, by [author name scrubbed], and CRS Report R44295, Factors Related to the Use of Planned Parenthood Affiliated Health Centers (PPAHCs) and Federally Qualified Health Centers (FQHCs), by [author name scrubbed]. |
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For more information about the Ryan White |
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|
HRSA, "Justification of Estimates for Appropriations Committees, |
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|
CDC, "National Breast and Cervical Cancer Early Detection Program," http://www.cdc.gov/cancer/nbccedp/. |
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|
CDC, "Justification of Estimates for Appropriations Committees, FY2016," p. 92 ff., http://www.cdc.gov/fmo. |
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HRSA, "Justification of Estimates for Appropriations Committees, |
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HHS, "Justification of Estimates for Appropriations Committees, General Departmental Management, |
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In |