Case Studies: How Tennessee and California Medicaid Programs Promote Access to Postpartum Long-Acting Reversible Contraception

Increasing women’s access to postpartum birth control has the potential to increase the health and well-being of women and their families, and immediate postpartum birth control can lead to a decrease in unplanned pregnancies, increased intervals between pregnancies, and a reduction in neonatal abstinence syndrome births (from drug exposure in the womb). Tennessee and California have developed unique Medicaid quality improvement and payment strategies to increase access to immediate postpartum long-acting reversible contraception (LARC).

Tennessee

In 2017, Tennessee’s Medicaid program (TennCare) in partnership with its managed care organizations (MCOs), updated and implemented a uniform billing policy for immediate postpartum voluntary LARC. LARCs include both intrauterine devices and implants. TennCare and its three MCOs agreed to implement a billing policy change to allow enrollees who chose a voluntary reversible long-acting contraception option to have increased access to their device of choice immediately following delivery during an inpatient stay.

The policy allows for reimbursement of the LARC device cost and the practitioner fee for insertion to be reimbursed separately from the global payment associated with the labor and delivery. Prior to the policy, services related to LARCs were considered part of the labor and delivery diagnosis-related group (DRG) payment and not separately reimbursable. The updated policy allowed hospitals and practitioners to file an additional claim for the device and the professional services in order to increase a woman’s access to immediate postpartum LARCs.

The Tennessee Initiative for Perinatal Quality Care (TIPQC) rolled out a project in 2017 focusing on immediate postpartum LARC to help support the implementation of the new Medicaid billing policy. TIPQC is the statewide perinatal quality collaborative that receives grant funding through the state. TIPQC chose to focus one of its statewide quality initiatives to improve the health of infants as well as eligible, desiring mothers in Tennessee by increasing access to contraception through systematically promoting and supporting immediate postpartum LARCs in the birth setting. The immediate goal of the quality improvement initiative was to increase access to immediate postpartum LARC to 50 percent of interested women at all participating hospitals by March 2019.

Once a hospital’s supporting structure was complete, the project aimed to increase placement in eligible women desiring immediate postpartum LARC to 70 percent by March 2019. Six hospitals throughout the state participated in the project and had a significant uptake in the number of LARCs placed immediately after delivery. All but one participating hospital was able to offer immediate postpartum LARCs by March 2019.

The sites’ initial barriers to implementation included reconfiguring their billing systems and training hospital coders to correctly submit claims to the MCOs for reimbursement. Dedicating team members to work with TennCare and coordination with all stakeholders were essential for implementation of the new policy. This updated billing policy and the quality improvement project were central strategies Tennessee used to help promote access to immediate postpartum LARCs.

California

During fiscal year 2019-2020, California’s Department of Health Care Services (DHCS) introduced value-based payment (VBP) measures for the state’s Medicaid program’s (Medi-Cal) managed care health plans (MCPs). The measures provide incentive payments to providers for meeting specific measure benchmarks designed to improve care. The California Healthcare, Research, and Prevention Tobacco Tax Act (Proposition 56) provided $250 million of the $544.2 million budgeted for incentive payments to providers. The incentive payments target physicians who meet the achievement metrics. These measures were formed with input from stakeholders and advocates, alignment with other DHCS quality efforts, and considerations of the number of impacted beneficiaries and administrative burden.

DHCS developed a set of VBP measures specific to prenatal and postpartum care. Among them is the postpartum birth control incentive payment to providers for provision of the most effective method, a moderately effective method, or LARC within 60 days of delivery. The postpartum birth control measure was to designed to improve the content and quality of postpartum care for mothers in California.

The payment to physicians is provided at the first occurrence of contraception within 60 days of delivery, with no more than one payment per delivery. Providers are required to report the delivery date for determination of the timing of when the contraception is received. Additionally, the incentive payment is not limited to live births. The standard add-on amount for postpartum birth control is $25 and the at-risk (serious mental illness, substance use disorder, or homeless conditions) add-on is $37.50. The postpartum birth control VBP measure supports the Centers for Medicare & Medicaid Services Child and Adult Core Set Measures for Contraceptive Care – Postpartum Measures (CCP-CH) for ages 15 to 20 and CCP-AD for ages 21 to 44. The CCP measures the percent of women who had a live birth who:

• Were provided a most effective or moderately effective method of contraception within 3 and 60 days of delivery; or
• Were provided a long-acting reversible method of contraception within 3 and 60 days of delivery.

The entire set of VBP program measures are implemented for a minimum of three years in the California Medi-Cal plan.

Conclusion

Tennessee and California each took different approaches to improve access to postpartum LARC.

• Tennessee Medicaid updated its billing policy to allow for separate reimbursement for the LARC device and LARC insertion, in addition to the standard global delivery DRG. It also coupled the policy change with a statewide quality improvement initiative to help implement the new policy.
• California Medicaid rolled out VBP measures, with a specific incentive payment for postpartum birth control provided within 60 days of delivery.

States that want to improve access to postpartum birth control can consider either billing policies or VBPs to promote this service. As policymakers are forced to make tough budget decisions, understanding the value and benefits of various strategies to improve women’s health will be increasingly important.

For more information on state Medicaid quality measurement activities for women’s health, explore NASHP’s interactive map State Medicaid Quality Measurement Activities for Women’s Health.

For more information on increasing access to LARCs in Medicaid, read a joint report by NASHP and the National Institute for Children’s Health Quality, Strategies to Increase Access to Long-Acting Reversible Contraception (LARC) in Medicaid.

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). Thanks to officials in Tennessee and California for reviewing their respective highlighted strategies. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.