Key takeaways
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With the overturning of Roe v. Wade, there may be an urgent must protect and expand access to contraceptive care.
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Extending quantity limits on contraceptive drugs, devices, and supplies—also referred to as one-year allotting and prolonged supply policies—could possibly be a promising avenue to extend contraceptive access and utilization on the state level. Prolonged supply policies would require health care plans and insurers to cover a one-year supply of contraceptives as determined on the discretion of the patient and health care provider.
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Nearly half of states—22 in total—of diverse geographic and political makeups have prolonged contraceptive quantity limits to cover up to at least one 12 months of certain contraceptives, mostly the pill, patch, and ring.
Introduction and summary
With the overturning of Roe v. Wade and lots of policymakers’ growing hostility toward reproductive health care, there may be an urgent need and opportunity to guard and expand access to contraceptive care.1 While many existing and emerging threats to reproductive health care are focused on restricting access to abortion,2 contraceptive services are also at stake despite strong public support.3 Indeed, experts have noted that while many contraception options have a “seemingly minuscule failure rate,”4 the stakes are even higher now given the country’s patchwork of maximum abortion bans5 and the pressure of navigating pregnancy prevention and planning.
While data that characterize pregnancy desires and intentions are limited, most estimates show that unintended pregnancies6 account for nearly half of all pregnancies in the US.7 These trends display a pronounced gap in the availability of reproductive health care services. While 65 percent of ladies—46.9 million overall8—from ages 15 to 49 currently use not less than one contraceptive method, many others have been systemically excluded from accessing comprehensive family planning services and contraceptive care. Greater than 19 million women in the US live in contraceptive deserts9—areas with insufficient access to the complete range of contraceptive methods—and this burden disproportionately affects women of color,10 who also are likely to report more negative health care experiences overall.11
Nonetheless, there are several promising legislative and regulatory policy reforms that states can pursue to mitigate burdens related to contraceptive access.12 Some states have already begun putting into effect policies to handle the fundamental barriers to access. To begin, one promising policy reform is to increase quantity limits on supplies of contraceptives covered by health care plans and insurance programs equivalent to Medicaid and personal insurers.
Read the accompanying fact sheet
Implementing one-year allotting
Conventionally, most insurance policy only cover one to 3 months of contraceptive supplies, that are typically oral contraceptives, hormonal patches, or vaginal rings.13 Nonetheless, that standard is slowly changing, with evidence suggesting that there are many benefits to making sure coverage of a one-year supply of some contraceptives for patients. Because of this, roughly half of states have begun implementing such a change. Nonetheless, many have encountered barriers which have kept the promise of the policy from being fully realized; a recent scan of states with 12-month mandates found relatively low 12-month prescription utilization rates, suggesting there may be room to enhance. 14 (see section on “Charting a path forward”) Particularly, policymakers should consider approaches that increase awareness and modernize training for providers; inform patients and apprise consumers of policy changes; optimize technology and medical management tools to correspond with policy updates; update mechanisms to advertise transparency and accountability; and, finally, promote a broader understanding of the advantages and evidence pool for one-year contraceptive allotting to counter common objections to the policy. More specific recommendations are provided at the tip of this report.
Burdens alleviated by one-year allotting
Quantity limits necessitate multiple unnecessary trips a 12 months to a physician for brand spanking new prescriptions, making health care particularly onerous and burdensome for people in search of contraceptive care. People in search of contraceptives must take into consideration travel time and costs, child care, and work schedules—amongst many other considerations—simply to coordinate a contraceptive visit. Emerging research also finds that ladies experience emotional and mental burden, as they often frequently assume the first responsibility of using contraception and stopping pregnancy; this anxiety is commonly reproduced through clinic visits and encounters with physicians.15 Because of this, small quantity limits increase the likelihood of contraceptive discontinuation and diminish women’s ability to plan their pregnancies. These burdens are particularly acute for ladies living in contraceptive deserts and rural areas who must travel long distances to acquire a prescription from a health care provider and fill it at a pharmacy.16 Moreover, extending the amount limits on contraceptives could help improve access for low-income people who find themselves uninsured or underinsured.17 About 30 percent of low-income and uninsured women depend on health centers and public family planning clinics to receive contraception in addition to other preventive services.18 Furthermore, low-income women are less prone to receive really useful preventive care and more prone to skip doctor’s visits due to cost.19
Overall, providing coverage for an prolonged supply of contraceptives can minimize disruptions in care and promote consistent use.20
Advantages in minimizing disruption in access to contraception
The importance of consistent use of contraceptives is evident. Many ladies depend on hormonal contraceptive methods for noncontraceptive purposes. For instance, some contraception could also be used to handle menstrual-related concerns or for other medical purposes, equivalent to managing menstrual pain, treating pimples, and managing endometriosis, as affirmed by the American College of Obstetricians and Gynecologists.21 Ensuring those individuals have consistent access to contraceptives will ensure continuity of look after those conditions as well.
However the top reason women select to make use of contraceptives is to time their pregnancies to their selecting. And it is evident that consistent use of contraception helps people select when to develop into or in the event that they wish to develop into pregnant.22 For example, one study found that ladies who received a one-year supply of oral contraceptives through California’s family planning program had a 30 percent reduction in unplanned pregnancies compared with women who received a one- or three-month supply.23 Not only does easier access to contraception mitigate these risks, however it also has been shown to have quite a few benefits, particularly relating to economic outcomes, educational attainment, and overall well-being for ladies.24 For instance, studies have found that early access to contraception, which is defined as access by age 20, reduces the likelihood that a lady resides in poverty,25 increases wages and earnings over a lifetime by as much as “5% more per hour and 11% more per 12 months,”26 and should increase highschool graduation27 and college enrollment rates.28
Along with the person health advantages of 12-month allotting, the cost-savings advantages for health programs and state economies have been clearly demonstrated as well. A 2019 Veteran Affairs (VA) Pittsburgh Health Care System probability study, which used a cohort of 24,309 women to estimate the prices of one-year allotting to the health care system compared with smaller supplies to estimate the prices to the health care system, demonstrated that 12-month allotting resulted in an annual cost savings of $87.12 per woman—which totaled $2,117,800 in annual savings—compared with the price of three-month allotting.29 Furthermore, it was estimated that switching to 12-month allotting would appreciably decrease unintended pregnancies. Likewise, an earlier 2014 study by the Washington State Health Care Authority (HCA) found significant cost savings after adopting a one-year contraceptive allotting policy. Specifically, the study showed that allotting 12-month supplies of contraceptives saved HCA $1.5 million in 2014 primarily consequently of averted births and their associated maternity and infant costs in 2014.30
Case studies: Approaches to implementing one-year allotting
Prolonged supply policies are likely to fall under the scope of administrative or regulatory law, particularly for Medicaid health plans or Medicaid-managed care plans (MCOs). Sometimes Children’s Health Insurance Program (CHIP) plans and student health advantages also cover contraceptives, which makes it easier for states to enact these policies independently and infrequently without modifying state budgets. The power to vary regulation of contraceptives and family planning without modifying states budgets is imperative, because states typically encounter more barriers with budget modifications, that are subject to legislature review and approval.31 States which can be hostile toward reproductive health care could also be less inclined to approve budget modifications even when the state’s executive branch supports such changes.
Nonetheless, state administrative agencies—equivalent to those who regulate state pharmacy standards, ensure the availability of appropriate health and social care services, regulate financial institutions, and more—can all take motion to revise existing regulations outlining contraceptive quantity limits and in addition issue updated regulations for insurers and health care providers and prescribers to follow.32
It must be noted that the implementation of prolonged supply policies is comparatively recent, as most states have only introduced these policies inside the past five to 6 years. As of the publication of this report, 22 states and the District of Columbia require certain insurers to cover an prolonged supply of contraceptives.33 In 2015, the District of Columbia was the primary to sign into law 12-month laws, and was quickly followed in 2016 by California, Hawaii, Illinois, Oregon, and Vermont.34 Since then, other states have followed suit, although to various degrees and with limitations or restrictions on a state-by-state basis. Common restrictions to 12-month contraceptive supply extensions include limiting these extensions to certain sorts of methods and devices, predominantly oral contraceptives, as they’re essentially the most common and most available approach to contraception, but increasingly, the patch and ring are being included in quantity-limit extensions. Other restrictions include limiting the variety of refills that may be made inside an insurance plan 12 months and requiring shorter periods for initial allotting. Additionally it is vital to notice that while these policies mandate insurers to cover a 12-month supply at one time, not all policies require a physician to prescribe contraceptives for 12 months at one time, meaning that a health care provider may sometimes use their discretion.
Below are examples of how some states have begun to revise policies, develop processes, and promote one-year allotting for contraceptives. These case studies usually are not designed to be comprehensive, and a few additional statistics from states are briefly described within the recommendations section of this report back to further explain the necessity for certain changes. The next examples display the growing momentum for administrative and legislative change in a various set of states.
Latest York
A 2014 study conducted by the Latest York Civil Liberties Union (NYCLU) found that “most insurance firms weren’t complying with federal and state law, including inappropriately charging cost-sharing and omitting coverage for various methods of contraception,”35 urging lawmakers to pass a bill referred to as the Comprehensive Contraception Coverage Act, which, amongst other provisions, allows for access to a one-year supply of contraception. Moreover, a Latest York State Department of Financial Services (DFS) investigation of 15 health plans revealed that the plans often provided incorrect and incomplete information to consumers regarding contraceptive coverage. Consequently, the DFS outlined three corrective actions to handle these errors:
- Require a corrective motion plan and related relief from all health plans that failed to offer accurate or complete information.
- Demand information and documentation from health plans regarding their coverage and reimbursement of contraceptive drugs and devices under medical health insurance policies. Specifically, the DFS will obtain details about contraceptive claims submitted and assess whether the claims were appropriately paid, with no cost-sharing imposed. The DFS can even investigate complaints and appeals involving contraceptive coverage.
- Take further regulatory motion as vital to make sure that all health plans cover the complete range of Food and Drug Administration (FDA)-approved contraceptive delivery methods at no cost-sharing.36
In 2017, Latest York established minimum standards for the sale of medical health insurance through the DFS,37 allowing an insurer to cover the allotting of an initial three-month supply of a contraceptive. For subsequent allotting of the identical contraceptive covered under the identical policy or renewal thereof, an insurer must cover as much as 12 months at the identical time. Later in 2019, Latest York signed into law S.B. S659A,38 enacting the Comprehensive Contraception Coverage Act, which went into effect in January 2020 and now requires insurers to cover a 12-month supply of a contraceptive for eligible people of childbearing age, including people under the age of 21.
In December 2019, the DFS issued a press release39 and circular letter40 to remind insurers of their responsibilities to cover all FDA-approved contraceptives, including 12-month supplies, with no cost-sharing and over-the-counter emergency contraceptives. In response to further noncompliance by three insurers—Aetna, MetroPlus Health, and Oscar Health—Latest York Attorney General Letitia James issued a press release demanding that they immediately comply and supply coverage for 12-month contraceptive supplies.41 As well as, each company received a letter outlining the importance of prolonged supply of contraceptives. James also urged anyone who has been wrongfully denied coverage to succeed in out to the office’s helpline and file a grievance.42 The investigation is ongoing.
Washington
In Washington state, the Health Care Authority (HCA) “modified the policy for oral contraceptive pills (OCPs) supply in 2014 by requiring the allotting of one-year packages for Medicaid recipients (under Section 213, Chapter 4, Laws of 2013, 2nd Special Session.”43 The policy change required that the Medicaid program cover a one-year supply upon prescription. One study found that while the 2014 policy was not implemented to the scope intended,44 it still saved $1.5 million—a mean of $226 per client—on maternity and infant care services because of averted births compared with those that received an initial one-month supply in 2014.45
In 2017, Washington State Legislature passed H.B. 1234, requiring “a health profit plan issued or renewed on or after January 1, 2018, that features coverage for contraceptive drugs must provide reimbursement for a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply.”46
South Carolina
As a part of its routine evaluation of the services provided through its Healthy Connections Medicaid program, South Carolina made several profit and reimbursement changes. In July 2020, the South Carolina Department of Health and Human Services amended the South Carolina Title XIX state plan to require the Medicaid program to cover a 12-month supply of systemic contraceptives, that are defined as oral contraception pills, transdermal contraceptive patches, and vaginal contraceptive rings.47 This requirement only applies to Healthy Connections Medicaid members. Notably, South Carolina reported that it doesn’t anticipate a budget change consequently of this policy.
Michigan
In 2022, Michigan, having reviewed other states’ policies on extending contraceptive supplies and following the Centers for Disease Control and Prevention (CDC) recommendations, implemented its prolonged 12-month per fill supply policy. That policy includes the availability of oral contraceptives, vaginal rings, and the contraceptive hormonal patches to Medicaid beneficiaries.48 The Michigan Health and Aging Services Administration (HASA) issued a policy bulletin update in June 2022 outlining the revised policy changes.49 An April 2022 bulletin also included clarifying language for pharmacy coverage, saying, “Contraceptive prescription drug claims must be billed at point-of-sale on to the Michigan Department of Health and Human Services,” while also stating that “medications might be subject to other existing Fee-for-Service (FFS) pharmacy policies and coverage limitations, including refill thresholds and prior authorization (PA) requirements.”50
HASA cited three key reasons for the uptake of the brand new 12-month policy: 1) reducing gaps in contraception continuation and unintended pregnancies; 2) improving pregnancy timing and spacing; and three) improving contraceptive equity and health outcomes while lowering direct costs of pregnancy management.51
Charting a path forward
With nearly half of all states having implemented some sort of prolonged supply contraceptive policy, the remaining states can utilize the present evidence base to tell their decisions for when and how one can develop and implement recent policies that meet their intended purpose and achieve measurable goals. Similarly, states with insufficient implementation may consider how one can modify their policies and practices to be more practical. As previously mentioned, most states with one-year mandates have relatively low utilization rates, suggesting there may be room to enhance.52
Statewide policy implementation is a multifaceted and sophisticated issue that requires coordination across many various agencies and organizations. The siloed adoption of a policy in a single sphere limits large-scale adoption of a policy and behavioral change. Likewise, policy and not using a direct implementation plan might be inadequate. Due to this fact, states must make a concerted effort to create actionable implementation plans, measurable objectives, and transparency and accountability structures.
Common challenges to implementing one-year supply policies and really useful solutions
Challenge: Provider awareness
A standard barrier to widely implementing 12-month allotting policies is a lack of expertise, education, and training initiatives needed to coach providers and pharmacists on recent policies and changes that happen. Currently, the communication channels usually are not robust, and lots of providers report minimal to no training on recent laws and subsequently how one can put these changes into practice. It’s imperative that providers and patients are aware of and educated on recent regulations to make sure the availability of quality, comprehensive care.
For instance, when Maryland passed the Contraceptive Equity Act of 2018, nearly all of clinicians surveyed were unaware of the brand new 12-month prescribing provision.53 Moreover, of the 38 percent of clinicians who did report being aware, only 13 percent said their prescribing practices modified due to it.54
Moreover, Massachusetts—which passed a 12-month allotting law in 2017—has provided a critical window into understanding the implementation issues that may arise. For instance, a CommonWealth investigation identified that the rollout of the brand new law could have been hampered since the state didn’t have a centralized way of providing updates on regulations to pharmacists and clinicians.55 Many providers were unaware of the 12-month allotting policy change. For instance, it appears providers may receive updates from each relevant state boards, specifically the Board of Registration in Medicine and the Board of Pharmacy, in addition to insurers, and that these updates are sent using either email or fax.56 Because most pharmacies in Massachusetts had not heard of the brand new law, physicians often needed to follow up with insurers directly to make sure patients were covered for his or her 12-month supply.57
To deal with this implementation barrier, policymakers should want to consider the next actions:
- Create a strong alert and notification system to extend awareness of recent policies and laws. As noted above, a qualitative study conducted after Massachusetts passed its Act Advancing Contraceptive Coverage and Economic Security in Our State (ACCESS) law in 2017 reported that some pharmacists really useful email alerts and notifications that contain a printable, informational flier and replica of the brand new policy.58
- Provide training opportunities. The identical study also found that nearly all of pharmacists recommend funding training and education opportunities that also offer continuing skilled education (CPE) credit. This may be a very important a part of skilled development and ensuring providers are on par with essentially the most recent guidance.
Similarly, states might need to construct or assign oversight to a working group or task force to develop and oversee training program opportunities and compliance. For instance, a part of Latest Mexico’s technique to increase access to long-acting reversible contraception (LARC) was to convene a LARC work group. The work group was facilitated by the reproductive justice organization Daring Futures and included key stakeholders equivalent to public health leaders, policymakers, clinical providers, and community members.59 In December 2016, the Latest Mexico Legislature appropriated funds to the University of Latest Mexico LARC Mentoring Program. This program offered statewide training, including publicly funded clinics, on contraceptive counseling and provision to clinicians and clinic staff and webinars on shared decision-making and reimbursement processes. With Medicaid administrative matching funds, the LARC Mentoring Program provided procedural training to 148 Medicaid clinicians on implants, 174 clinicians on intrauterine devices, and 18 clinicians on immediate postpartum LARC. In the identical 12 months, the Family Planning Program, which is run by the Latest Mexico Department of Health, and the University of Latest Mexico launched the virtual reproductive health clinic using the Extension for Community Healthcare Outcomes model.60
Latest Mexico successfully integrated separate projects focused on immediate postpartum and interval LARC to deliver clinical and administrative training and support to 3 geographic regions, three hospitals, two federally qualified medical institution networks, and greater than 50 clinicians and administrative staff.61
Challenge: Patient awareness
One other barrier is patient education and awareness. Much like the above recommendations, states must also tailor their educational campaigns to maintain patients who may use contraceptives informed of changes, while also affirming patients’ right to advocate for themselves:
- Fund and adequately staff hotlines with staff who’re knowledgeable of contraceptive care services.62 Many state Medicaid-managed care programs and personal health plans operate toll-free hotlines for enrollees. In a single survey study in Washington state, hotline representatives regularly struggled to reply or couldn’t appropriately answer specific inquiries about contraceptive services and advantages.63Moreover, when Massachusetts passed the Contraceptive ACCESS law in 2017, research showed that only 300 women obtained a 12-month supply of contraception over the course of 2020 through the state’s largest insurers, despite the fact that greater than 1 million patients were eligible.64
- Use a multifaceted approach to notify insured patients of changes. This includes posting updates about any policy changes through each electronic and print notifications, including email, regular mail, and alert notification systems. This also includes posting details about policy changes on insurers’ web sites and including links to resources for more details about who to contact with questions or concerns.
Challenge: Technology adaptation and medical management
A 3rd barrier is that while recent technologies have made patient record management more efficient, they can be slow to uptake and reflect recent administrative policies. For instance, Massachusetts physicians reported encountering problems in prescribing a 12-month supply of contraception due partially to electronic medical record (EMR) systems often defaulting to the usual one- or three- month supply.65 To deal with this, states and the medical field should work together:
- Facilitate smooth changes to EMR software that coincide with policy changes. Moreover, one study assessed the impact of a default order change in EMR software in multiple outpatient facilities in California. It found that changing the default order to 12-month allotting, reasonably than one-month prescriptions with refills, modified prescribing practices.66 Overall, prescribers ordered 260 12-month prescriptions, or 11 percent of total prescriptions written, before the EMR change and 669 12-month prescriptions, or 27 percent of total prescriptions written through the specified time period, after the change.
Challenge: Transparency and accountability
One other barrier to one-year contraceptive allotting is a dearth of accountability and research on the effectiveness of some allotting policies. Latest policies will only be effective with coordinated dissemination of data and measurable, actionable changes, equivalent to the next:
- Procure research and create data teams and contracts with third-party professionals to conduct independent assessments and implementation evaluations. These groups might be key to learning if and the way effective a policy is. Public outreach strategy and the dissemination plan must be determined well upfront.
By way of accountability, one study of California’s implementation of year-long contraception found that nearly all of pharmacists stated that the largest perceived obstacle for allotting a year-long supply of contraception at one time was whether insurance firms would supply appropriate reimbursement, which was supported by the evidence as only 55 percent, or 297 out of 532 prescriptions, were appropriately reimbursed.67 For this reason distrust of insurance firms, many pharmacists weren’t willing to dispense the complete 12 months’s supply, despite California state law mandating that they achieve this. This further shows the dire role that insurers play in improving or hindering access to contraceptive care. As such, health plans should develop written policies that provide meaningful direction to employees and providers to make sure compliance. These policies should include organizational processes for coping with compliance issues.
- Issue all plan letters (APLs) and guidance on best practices to offer clarification regarding contraceptive quantity limits and supplies. As mentioned by the National Health Law Program, “the APL is a very important tool since it brings recent law to the eye of plans, sets expectations for compliance, and provides a degree of contact inside the state regulator’s office.”68 APLs are also issued on the federal level to direct insurance compliance. For instance, the Biden administration sent out letters earlier this 12 months as a reminder to comply with the Reasonably priced Care Act contraception coverage rule that requires insurers to cover not less than one FDA-approved contraception method under each device category.69 Many health plans and insurers haven’t been in compliance with this requirement.70 The truth is, a giant portion of health insurers and pharmacy profit managers impose cost-sharing requirements and coverage exclusions which can be against federal guidelines.71
Challenge: Fears of contraceptive waste
Finally, one remaining barrier to implementation is the priority that allotting a one-year supply of contraceptives at one time can result in product waste. This concern can hinder state willingness to adopt and implement this policy, especially when the priority is shared by insurance firms and policymakers.
In California, for instance, insurance firms initially opposed the 12-month supply policy because they believed that folks may not use a full 12-month stock of their contraceptives or may switch methods partway through the 12 months, and subsequently, medications that the insurance company had paid for could be thrown out. Nonetheless, a technique that the state addressed this concern was by sharing the research supporting the advantages of a 12-month supply. A professor on the University of California, San Francisco studied these advantages and located that a one-year supply resulted in lower costs and fewer unintended pregnancies.72 The health costs related to an unintended pregnancy far outweigh those of potential product waste.
Conclusion
One-year allotting is a vital policy option that may significantly increase contraceptive access. One-year supply policies may also help mitigate a few of the burdens related to monthly contraceptive prescribing and allotting and bolster access for the tens of millions of ladies who use monthly contraception options. When implemented effectively and to scale, one-year supply policy has the flexibility to assist make sure that women can determine when or when to not have children and promote bodily and reproductive autonomy. Policymakers can look to a few of the aforementioned states as models on how one can start in designing a one-year program that’s tailored properly to their respective state.
Acknowledgements
The creator would really like to thank Osub Ahmed, Bela Salas-Betsch, Amina Khalique, Elyssa Spitzer, Maggie Jo Buchanan, and Tracy Weitz for his or her contributions to and reviews of this series.