How Medicare Fails Enrollees' Reproductive Health Needs

Medicare is often considered an insurance program for the aging population; however, approximately 1 million women of reproductive age who are disabled or have severe health conditions have primary health coverage through Medicare. ¹ These patients navigate a complex health care system, yet are denied basic reproductive needs such as contraception and family planning services. This loophole in Medicare coverage is a disservice to an already at-risk population and can lead to unintended and potentially devastating outcomes for patients and their families. Now more than ever, the Centers for Medicaid and Medicare Services (CMS) need to address the disparate coverage of essential reproductive services for Medicare enrollees.

Despite the contraceptive mandate instituted by the Affordable Care Act (ACA) requiring most insurances to cover 18 contraceptive methods with no cost sharing, Medicare is not legally required to cover contraception. Notably, 65% of all women aged 15–49 years were using a form of contraception between 2017 and 2019, but Medicare Parts A and B do not explicitly provide coverage for these methods. ² Some Medicare Advantage plans, or private contracted plans, and some Medicare Part D prescription drug coverage plans will include this benefit but are not subject to the ACA mandate. ^1,3

A patient arriving for her annual examination can receive routine cervical and breast cancer screening, testing and treatment for sexually transmitted infections, recommended vaccinations, but not birth control due to inadequate coverage. Although Medicare plans may offer coverage of hormones due to medical necessity, such as fibroids or ovarian cysts, patients cannot be covered for contraception for pregnancy prevention. Essentially, Medicare coverage as it stands now undermines a young patient's right to receive contraception, a notion that most reproductive health providers would find problematic, illogical, and potentially life threatening for some disabled patients.

Medicare also does not cover sterilization procedures, one of the most popular forms of contraception used by almost two-fifths of all reproductive aged women, unless the procedure is part of treatment for an existing condition. ² Consider a patient with end-stage renal disease where pregnancy could be catastrophic and potentially lethal. Consider another patient undergoing expensive and emotional cancer treatments who cannot safely receive hormonal birth control, and would be asked to pay out of pocket for what is deemed an “elective” procedure. For many young patients who battle conditions that qualify for Medicare coverage, pregnancy prevention is not a choice—it is a matter of life or death.

In addition to a lack of coverage for birth control, Medicare cannot cover abortion services due to the Hyde Amendment, a Congressional stipulation that prevents federal funding for abortion care. Assessing reproductive health needs for patients with disabilities is challenging for patients and providers alike and involves dynamic decision making over the course of a patient's reproductive years. Medicare enrollees already battle stigma, coercion, and discrimination when navigating reproductive health choices, and the Hyde amendment further undercuts their reproductive autonomy. ⁴ In addition, state-specific access to abortion care can include mandatory waiting periods, long travel times, and early gestational age limits. Such restrictions along with lack of insurance coverage can disproportionally impact those on Medicare from accessing a medically necessary service such as access to safe abortion.

Approximately 70% of Medicare beneficiaries of reproductive age are dual-eligible, that is, supplement Medicare coverage with Medicaid due to financial hardship. ³ Medicaid, as the largest financier of publicly funded family planning services, plays an essential role in ensuring access to care for dual-eligible enrollees, particularly when Medicare denies coverage. ^1,3 Although federal law requires states to include family planning services in their Medicaid programs, many barriers to eligibility and coverage remain. Access to a full range of family planning services depends on whether an enrollee's state has traditional Medicaid (i.e., pre-ACA expansion), Medicaid expansion, or Medicaid Family Planning Expansion programs. ⁵

State Medicaid programs vary tremendously in terms of covered contraceptive methods, prior authorization and prescription requirements, and reimbursement policies. For example, not all states cover any or all forms of emergency contraception. A few states impose authorization and utilization controls for long-acting reversible contraception methods, despite a recommendation by the American College of Obstetricians and Gynecologists in support of same-day provision. Some states have even implemented policies to exclude certain family planning providers from their Medicaid programs, further exacerbating the challenges individuals face when seeking care.

Medicaid cannot and should not be the stop-gap measure for Medicare's inability to cover essential services for a large percentage of its beneficiaries. Dual-eligible patients are arguably one of the most vulnerable yet resilient populations any reproductive health provider can care for—persons who disproportionately take on the burdens of limited access and delays of care, despite their own health conditions.

In addition to restricted family planning services, limits to accessing comprehensive reproductive health care are compounded for Medicare enrollees who identify as a sexual minority. Similar in approach to contraception coverage, Medicare will cover medically necessary transition; however, this care is subject to the discretion and constraints of state-specific plans and coverage protocols. Medicare enrollees who seek gender-affirming care should be empowered and not encumbered by their coverage plan to achieve their health needs.

Young patients with conditions that qualify for Medicare coverage are those who agonizingly steer through a complicated health care system. These patients face countless hurdles in achieving the rightful and appropriate care they need. There are many actions health care providers can take to support the right to reproductive services for these patients. We call on providers to consider the following: 1.

Educate yourself on what Medicare covers or does not cover in your state.