Title

Beyond the freedom to choose. Medicaid, managed care, and family planning

Document Type

Journal Article

Publication Date

9-1995

Journal

Western Journal of Medicine

Volume

Volume 163, Supplement 3

Inclusive Pages

33-38

Keywords

Family Planning Services--organization & administration; Health Services Accessibility; Managed Care Programs--organization & administration; Medicaid--organization & administration; Women's Health; Community Health Centers; Disparities; Health Homes

Abstract

In the mid 1980s, Congress passed legislation that exempted family planning (FP) services from restrictions on the ability of Medicaid managed care enrollers to choose their own health care provider. This aimed to protect access to timely and confidential FP services. Yet, it has resulted in new problems (e.g., isolation of public FP programs). Carving out FP services allowed Congress to avoid dealing with the structural shortcomings of managed care. This review examines how the freedom-of-choice law has been implemented in 15 jurisdictions and FP programs in Michigan, Illinois, Florida, Minnesota, and Pennsylvania. The extent to which the law has been able to reach its objectives depends on: the degree to which the definition of exempt FP services actually include all FP items and services that patients might seek on a confidential basis; the degree to which the exemption applies to all potential managed care arrangements; and whether the Health Care Financing Administration and state agencies have implemented the exemption in a manner consistent with the best interests of patients to ensure access to timely, confidential, and comprehensive FP services. Essentially no federal standards in implementing the statute exist. The five states allow health plans to decide for themselves how the FP preferences of enrollers will be honored. Pennsylvania is the only state to use the freedom-of-choice law as a springboard for integrating FP providers into managed care. The other states are faced with many problems revolving around referrals for covered services not offered, lengthy payment delays, and claims for services. Minnesota requires all network-style managed care plans to contract with all family planning providers in their service areas. Based on these findings, the researchers recommend voluntary integration of already-existing providers in underserved communities into managed care systems. If health plans choose not to voluntarily integrate these providers, legislation should be passed requiring them to do so if they wish to do business in underserved communities. Carve-outs should be the last resort since they are difficult to design.

Peer Reviewed

1