Postpartum Long-Acting Reversible Contraception
The timing and spacing of pregnancy not only affect health, social and economic outcomes for individuals and their families, but can also have broad societal implications. Responding to the high costs of unplanned pregnancy for women, families and states, some state leaders have explored strategies to help women plan, space or prevent future pregnancies. Some states are increasing access to long-acting reversible contraception (LARC) during the postpartum period to reduce unplanned pregnancies. LARC methods describe types of birth control that provide long-term pregnancy prevention, including intrauterine devices (IUDs) and hormonal implants. They are one of the most reliable and common pregnancy prevention strategies and can make a particular impact during the postpartum period.
For example, one study found that immediate postpartum LARC placement averted 88 unintended pregnancies per 1,000 women over two years. This could save more than $3,200 in medical costs for each unintended pregnancy. In addition to direct health costs, LARCs can also help avoid broader public welfare costs in programs that serve young, low-income women and their children, such as Medicaid and the Temporary Assistance for Needy Families program. When Colorado provided LARCs to individuals with low incomes, teen birth rates and teen abortion rates dropped by half and the state saved nearly $70 million in public assistance costs over a five-year period.
Women who experience an unplanned pregnancy are less likely to receive prenatal care and may have a higher risk for postpartum depression and mental health problems later in life. Unintended pregnancies have been associated with higher rates of preterm birth and low birth weight. One analysis estimated the immediate direct medical costs of unintended pregnancy to be $5.5 billion in 2018, an increase from $4.6 billion in 2011 despite declines in unintended pregnancy rates.
In the first year postpartum, at least 70% of pregnancies are unintended, 10-40% of women do not attend their postpartum visit and 40-75% of women who plan to use an IUD postpartum do not obtain it.
Barriers to LARC provision include a lack of provider training and the inability to perform same-day insertion, which together limit overall use. While LARC methods are incredibly cost-effective, they come with a high upfront cost, often upward of $1,000. Also, many payers do not reimburse for a LARC device immediately after delivery. To reduce these barriers, state policymakers are exploring a range of strategies to help women plan, space or prevent future pregnancies during the critical postpartum period.
State Policy Options
States have acted in recent years to improve reimbursement, address funding and provide education to remove barriers to postpartum LARC.
States are increasingly unbundling the cost of LARC devices and insertion from other postpartum services to increase reimbursement rates. Traditionally, Medicaid and commercial payors paid for postpartum LARCs as part of a global payment for labor and delivery, meaning that providers were not separately reimbursed for the cost of the device or the placement of the device. In 2016, CMS issued an informational bulletin outlining Medicaid payment strategies state could use to remove barriers to LARCs, including unbundling payments.
States have used these payment strategies in both Medicaid and commercial insurance. At least 26 states separately pay providers for both the cost of the device and for provider placement, 30 states separately pay for the cost of the device, and 34 states separately pay for provider placement.
Most states have also issued guidance on Medicaid reimbursement for postpartum LARC provided in the hospital setting. Illinois requires commercial health plans to allow hospitals separate reimbursement for LARC devices provided immediately postpartum in the inpatient hospital setting before hospital discharge. Mississippi requires any contractors receiving payments under a managed care delivery system to work with providers of Medicaid services to improve the use of LARC.
Some states address LARC access through funding mechanisms. Virginia’s 2018 and 2021 budget bills included funding to expand access to LARC methods. The 2018 funding allocated federal funds to a two-year pilot program that provided approximately 4,000 no-cost visits for LARC to eligible patients. In 2018, New Mexico appropriated $250,000 to purchase LARC devices to improve same-day access and for provider training. In 2022, Indiana appropriated $700,000 to expand Medicaid LARC coverage.
Lastly, states can increase access to LARC through education. For example, West Virginia requires pharmacists who dispense self-administered hormonal contraceptives to provide patients with information on the effectiveness and availability of LARC.
Section 2713 of the Patient Protection and Affordable Care Act (ACA) requires all non-grandfathered group health and individual health insurance plans to cover certain preventive health services with no cost sharing (e.g., copayment, coinsurance, or deductible). This includes coverage for all contraceptive methods approved by the U.S. Food and Drug Administration, including LARCs, subject to religious exemptions and accommodations for certain employers.
Federal law also requires states to cover prescription contraception without cost-sharing in the state’s Medicaid plan as part of the mandatory family planning benefit. States have flexibility to specify the services, supplies, payment methodologies and providers that are included in the Medicaid family planning benefit as long as patient freedom of choice is preserved and federal coverage requirements are met or waived through Section 1115 demonstration waivers. Most states cover LARC methods through their Medicaid family planning benefit.
Under the federal Health Center Program, federally qualified health centers (FQHCs) play an integral role in providing contraception to low-income and uninsured individuals. The Title X family planning program has enabled many FQHCs to keep LARC in stock by covering the devices’ up-front costs. FQHCs may also enroll in the 340B Drug Pricing Program, which entitles them to purchase LARCs at a discounted price.
Evidence indicates that policies unbundling payments for postpartum LARC are having the intended effect. A study in South Carolina found the policy change to be associated with increased LARC use and that women who received immediate postpartum LARC were less likely to have a subsequent short-interval pregnancy. Another study of five states found that Medicaid reimbursement of immediate postpartum LARC was associated with a statistically significant increase in the rate of LARC placement.