States are using a variety of strategies to improve access to postpartum contraceptive care, including coverage, payment, and quality levers to increase access to long-acting reversible contraception (LARC). Access to effective contraception soon after having a baby can help avoid unintended or mistimed pregnancies, which may put a person’s health, and that of a subsequent pregnancy, at risk.
State Medicaid strategies for improving access to postpartum contraceptive care, including LARC
Payment
Connecticut’s Medicaid Pay for Performance in Obstetrics Care Program aims to improve care of pregnant women, newborn outcomes, and the incidence of avoidable mortality and morbidity. The state’s Medicaid program provides bonus payments to obstetric providers if they meet certain quality and access measures in treating Medicaid patients. One of the measures for which providers can earn points toward bonus payments is whether a comprehensive postpartum visit occurred between 22 and 84 days after delivery. This visit must include future pregnancy planning and contraceptive options, among other topics.
Many states have unbundled immediate postpartum LARC placement from the global maternity fee in Medicaid. Bundling LARC placement with the global maternity fee (which includes professional services provided during the perinatal period, including prenatal care, labor and delivery, and postpartum care) does not compensate the provider for the cost of the LARC device or the fee to place the device. A study found that this Medicaid reimbursement strategy is associated with an increase in the rate of the provision of LARC for postpartum women. State examples include:
South Carolina was the first state to unbundle postpartum LARC in Medicaid in 2012. A study found that the odds of receipt of immediate postpartum LARC increased following this policy change in the state, and immediate postpartum LARC utilization was associated with decreased odds of a subsequent short interpregnancy interval.
After Virginia unbundled Medicaid reimbursement for the LARC device and insertion procedure fee prior to hospital discharge, the Virginia Postpartum LARC Workgroup developed a toolkit for hospitals to facilitate offering and obtaining payment for postpartum LARC. The workgroup is a coalition of the Department of Health, Department of Medical Assistance Services (Medicaid), the state section of the American College of Obstetricians and Gynecologists, and other partners in the state.
After Washington state implemented separate Medicaid payments for immediate postpartum LARC insertion and increased provider payment rates, an evaluation showed an increase in the use of LARC in the postpartum period of three and 60 days after delivery. This increase was highest for teenagers and Hispanic women.
Coverage
Medicaid coverage typically ends 60 days after delivery, but increasingly states are receiving federal approval to extend coverage to 12 months postpartum to support maternal and infant health. As of January 2023, 28 states and Washington, DC, have implemented this extension, and several more have plans to do so. This extended coverage provides an opportunity to ensure women receive needed health services, including counseling about contraceptive options such as LARC. Researchers evaluating the impact of postpartum Medicaid coverage beyond 60 days found members with extended postpartum coverage used 10 times as many contraceptive services and 37 percent fewer services for subsequent pregnancies compared to those who lost Medicaid coverage at 60 days.
Quality
States also use Medicaid quality measures to track and promote postpartum LARC access.
The Maternity Core Set is a group of quality measures that states can voluntarily report to the Centers for Medicare & Medicaid Services (CMS). It includes two postpartum contraceptive care measures for the proportion of women who received contraception (a most effective, moderately effective, or LARC method) within three and 60 days of delivery. In 2021, 36 states reported this measure for ages 15–20, and 34 states reported this measure for the 21–44 age group.
In alignment with the Maternity Core Set, several states include access to postpartum contraception in their Medicaid managed care quality strategies. States must develop and update these strategies to assess and improve the quality of managed care services.
As part of its objective to improve maternal health, DC’s 2020 Medicaid Managed Care Quality Strategy includes a postpartum contraceptive care measure tracking the proportion of women provided with LARC three to 60 days after delivery.
North Carolina’s 2021 Medicaid Managed Care Quality Strategy incorporates contraceptive care measures, including one for postpartum contraceptive care.
What is LARC and its impact on postpartum patients?
LARC methods last several years and are reversible, which makes them convenient for many people, including postpartum women. Because it is possible to get pregnant very soon after having a baby, using a birth control method immediately after giving birth helps to avoid unintended pregnancies. Postpartum contraception can reduce short interpregnancy spacing, which is associated with health risks for both the infant and the person giving birth. LARC methods can be placed while the pregnant person is still in the delivery room or hospital after childbirth. This means postpartum individuals will not have to return later for a separate visit for the LARC device and can go home with a safe, effective birth control method.
LARC methods include the intrauterine device (IUD) and the birth control implant.
IUDs
IUDs are small “T” shaped devices placed inside the uterus by a health care provider. There are two types of IUDs:
- Hormonal IUDs (also called levonorgestrel intrauterine system, or LNG IUD), which release a small amount of progestin each day to prevent pregnancy. These last for three to eight years and have a failure rate of 0.1 to 0.4 percent. Four brands are available in the U.S.: Mirena, Liletta, Kyleena, and Skyla.
- Copper T IUDs are nonhormonal IUDs with a failure rate of 0.8 percent. These devices work by releasing a small amount of copper into the uterus and last for up to 10 years. ParaGard is the only brand available in the U.S.
Contraceptive implants
The contraceptive implant is a thin rod inserted into the arm that contains progestin, which is released over three years. The failure rate is 0.1 percent. One type of contraceptive implant, called Nexplanon, is available in the U.S.
What barriers do providers and patients face accessing LARC?
For providers, the high cost of the device makes it expensive to keep on hand in the office, and low Medicaid reimbursement rates can hinder LARC provision. Some providers use a two-visit protocol for LARC due to insurance or screening protocols, which requires patients to return for a follow-up visit to insert the LARC. This creates a logistical barrier; one study found that approximately half of Medicaid-insured women who requested an IUD returned for the insertion visit.
This product was made possible through generous support from Arnold Ventures.