The vast majority (83%) of Title X–funded family planning clinics in the United States have one or more established contracts with public and private health insurance plan issuers in their area, according to a new analysis by Guttmacher experts Mia Zolna, Megan Kavanaugh and Kinsey Hasstedt, just published in Women’s Health Issues. For each contract, the clinic must work to ensure that the plan issuer covers needed services as appropriate and adequately reimburses the clinic for the services provided.
In a 2015 nationally representative survey of 535 Title X–funded clinics (including health departments, Planned Parenthood affiliates, federally qualified health centers and other community-based and hospital clinics) and 23 in-depth interviews with clinic administrators, respondents identified the extent to which they had established contracts with insurance plan issuers and their strategies for doing so. Successful strategies included taking a proactive approach to contacting and establishing relationships with plan issuers, negotiating contracts as part of a system of providers, and employing staff with experience in contracting or insurance.
"Publicly funded family planning clinics are a critical source of care for millions of individuals, including low-income women and adolescents," says Mia Zolna, lead author of the analysis. "It is important that the high-quality contraceptive services they provide are affordable to their clients and that clinics can sustain their ability to deliver such care."
Despite the prevalence of insurance plan contracts—which other studies indicate has increased in recent years—clinic administrators reported challenges in working with plan issuers. Under federal law and regulations, Medicaid and most private plans must cover family planning services without cost sharing and must limit other barriers, such as prior authorization requirements. Many clinic administrators reported successful resolution of disputes with plan issuers over coverage requirements specific to the Affordable Care Act (ACA) since the initial implementation of these regulations. However, some administrators reported that they were still encountering plan restrictions, including plans not covering specific contraceptive products, limiting the initial contraceptive supply or the number of refills that could be prescribed, and requiring prior authorization for coverage of specific methods.
Some clinics also had difficulty obtaining adequate and timely reimbursement from health insurance plans. For example, some were not reimbursed because clients were required to obtain a contraceptive product at a pharmacy in order to use their insurance coverage. In some instances, claims were denied or clinics experienced long lag times between submitting a claim and receiving reimbursement. Additionally, reimbursement rates were not always sufficient to cover the cost of the services provided.
The most effective strategies for successfully overcoming coverage and reimbursement challenges centered on clinic employees. Administrators reported that employing and offering ongoing training to staff who understand the complexities of the health insurance system and can cultivate good working relationships with plan issuers enabled clinics to negotiate better contracts and more consistently obtain reimbursement for all covered services.
"Despite the sustained efforts of clinic staff, policymakers are seeking to undermine critical programs and policies that clinics rely on, including Title X, Medicaid and the ACA’s contraceptive coverage guarantee," says Kinsey Hasstedt, co-author of the analysis. "Taken together, these attacks pose an unprecedented threat to the ability of safety-net family planning providers to continue delivering affordable, high-quality family planning services."
"Insurance-Related Practices at Title X–Funded Family Planning Centers under the Affordable Care Act: Survey and Interview Findings," by Mia Zolna, Megan Kavanaugh and Kinsey Hasstedt, is currently available online and will appear in a forthcoming issue of Women’s Health Issues.