Family Planning Only interim evaluation report CMS approval letter

Washington State’s

1115 Family Planning

Demonstration Interim

Evaluation

Findings from July 2018 to

June 2022

May 1, 2023

Clinical Quality and Care Transformation Division

P.O. Box 45502

Olympia, WA 98504

Phone: (360) 725-1612

Fax: (360) 586-9551

hca.wa.gov

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Washington State’s 1115 Family Planning Demonstration Interim Evaluation ...................................................... 1

Findings from July 2018 to June 2022 ................................................................................................................... 1

Acknowledgements ..................................................................................................................................................... 3

Executive Summary ..................................................................................................................................................... 4

Key Findings ............................................................................................................................................................. 4

Introduction and Background ..................................................................................................................................... 5

Evaluation Questions and Hypotheses ...................................................................................................................... 6

Demonstration Objectives: ..................................................................................................................................... 6

Summary of Key Evaluation Questions and Hypotheses ................................................................................. 6

Methodology ................................................................................................................................................................ 7

Data ........................................................................................................................................................................... 7

Medicaid eligibility, enrollment, and claims data ............................................................................................ 7

First Steps Database (birth certificates linked to Medicaid clients ................................................................. 7

Pregnancy Risk Assessment Monitoring System (PRAMS) survey ................................................................... 7

Methods .................................................................................................................................................................... 7

FPO Waiver Study Populations .......................................................................................................................... 8

Definitions and Measures ................................................................................................................................... 8

Quantitative Methods ......................................................................................................................................... 9

Methodological and Study Limitations ................................................................................................................ 10

Results ........................................................................................................................................................................ 12

Family Planning Services .................................................................................................................................. 14

Family Planning-Related Services ................................................................................................................... 16

Disenrollment and Retention ........................................................................................................................... 17

Special Population ............................................................................................................................................ 18

Maternal and Child Health Outcomes .............................................................................................................. 18

Unintended Pregnancies .................................................................................................................................. 19

Discussion ................................................................................................................................................................... 20

Lessons Learned and Recommendations ................................................................................................................ 21

References .................................................................................................................................................................. 22

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Acknowledgements

We want to acknowledge the work of our colleagues and our partner programs for all the work they do in serving

Washington’s vulnerable populations.

This document is part of a series of reports produced by Clinical Quality and Clinical Transformation (CQCT) with

assistance from the DSHS Research and Data Analysis in evaluating the FPO waiver during its renewal from July

2018 through June 2022. Evaluations are required components of waiver renewals and are stipulated in the

Special Terms and Conditions (STCs).

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Executive Summary

THE 1115 FAMILY PLANNING DEMONSTRATION WAIVER in Washington State provides family planning and

family planning-related services to low-income individuals not otherwise eligible for Medicaid. While the

program has undergone significant state and federal policy changes over the most recent waiver period, it

continues to provide valuable confidential family planning services. This report describes the access to and

utilization of family planning and family planning-related services and how these services are impacting

maternal and child outcomes in Washington State. The study examines three target populations eligible for

Family Planning Only (FPO) services separated based on income level or pregnancy status: 1) FPO Pregnancy-

Related, 2) FPO Lower Income, and 3) FPO Higher Income during the most recent waiver period, July 1, 2018

through June 30, 2022.

Family Planning Only Family Planning Only Family Planning Only

Recently pregnant who lose Medicaid

coverage after their 60-day post

pregnancy coverage ends



FPO Pregnancy-Related

Women or men at risk of unintended

pregnancy with incomes over 133% to

185% Federal Poverty Level



FPO Lower Income

Women or men at risk of unintended

pregnancy with incomes over 185%

to 260% Federal Poverty Level



FPO Higher Income

Key Findings

1. During the 2018-2022 Family Planning Waiver period, the State enrolled 29,164 individuals and

provided 56,425 family planning and family planning-related services to 9,205 unique clients. Peak

enrollment occurred in October 2018 at 7,971, and then declined 72 percent from March 2020 to December

2020 with the COVID-19 global pandemic quarantine measures.

2. The COVID-19 quarantine, associated healthcare access restrictions, and subsequent Public Health

Emergency (PHE) eroded enrollment and participation gains from the pre-pandemic period. The PHE

allowed many eligible FPO Pregnancy-Related clients to maintain full-scope Medicaid coverage after their

pregnancy ended explaining most of the decreased enrollment in the overall waiver population.

3. Twice as many FPO Lower Income clients utilized family planning and family planning-related waiver

services than the other waiver groups. By DY2021, 57 percent of FPO (Lower Income) clients utilized a

family planning and family planning-related waiver service compared to 29 percent of FPO (Higher Income)

and 13 percent of FPO (Pregnancy-Related).

4. According to PRAMS survey results, the proportion of Washington State unintended births have declined

over the years in the current waiver period.

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Introduction and Background

Washington State’s 1115 Family Planning Waiver Demonstration was originally approved by the Centers for

Medicare and Medicaid Services (CMS) and has been consistently extended since 2001 (1). The Demonstration

covers every FDA-approved birth control method and a narrow range of family planning services that help

clients use their contraception safely and effectively. The overarching program goals of the Demonstration have

remained consistent since the initial approval (Table 1).

TABLE 1

Program Description

Program Goals

• Improve access to family planning and family planning related-services.

• Decrease the number of unintended pregnancies.

• Increase the use of contraceptive methods.

• Increase the interval between pregnancies and births to improve positive birth and

women’s health outcomes.

• Reduce state and federal Medicaid expenditures for averted births from unintended

pregnancies.

DEMONSTRATION

POPULATION

NAME

Historic

Family Planning Only Extension

Take Charge

Current

 Family Planning Only – Pregnancy-

Related (Effective 7/1/19)

 

Family Planning Only (Effective 7/1/19)

Income eligibility

• Income at or below 198 percent of the

federal poverty level (FPL).

• Income at or below 260 percent of the federal

poverty level (FPL).

• Lower income – uninsured with family income

>133 percent to 185 percent of FPL.

• Higher income – uninsured with family income

>185 to 260 percent of FPL.

Target population

• Recently pregnant women who lose

Medicaid coverage after their 60-day

post pregnancy coverage ends,

regardless of pregnancy outcomes

and who are not eligible for Apple

Health (Medicaid) coverage.

• Uninsured women and men seeking to prevent

unintended pregnancy and who are not eligible

for Apple Health (Medicaid) coverage.

• Teens and domestic violence victims who need

confidential family planning services.

Coverage period

• Additional 10-month coverage

following the standard Medicaid 60-

day post-pregnancy coverage.

• When coverage ends, must apply for

Medicaid or Family Planning Only

• 12-month coverage.

• No limit on how many times one can reapply

for coverage.

Program coverage

• Family planning services for women,

which include an annual

comprehensive family planning

preventive visit. Family planning-

related services include screening for

gonorrhea and chlamydia for women

ages 13 through 25, cervical cancer

screening, and services directly

related to successfully using a chosen

method of contraception.

• Family planning services for women, which

include an annual comprehensive family

planning preventive visit. Family planning-

related services include screening for

gonorrhea and chlamydia for women ages 13

through 25, cervical cancer screening, and

services directly related to successfully using a

chosen method of contraception.

• Family planning services for men, which

includes an annual counseling session for

reducing the risk of unintended pregnancy,

condoms and spermicides, and services

directly related to vasectomies.

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Evaluation Questions and Hypotheses

To evaluate whether Washington State’s FPO program achieved its objectives, the following evaluation

questions were addressed:

Demonstration Objectives:

There are three demonstration objectives that were measured during the interim evaluation. 1) Ensure access

to and utilization of family planning and/or family planning-related services for individuals not otherwise

eligible for Medicaid, 2) Improve or maintain health outcomes for the target population as a result of access to

family planning and family-planning related services, and 3) Reduce the number of unintended pregnancies in

the waiver population.

Summary of Key Evaluation Questions and Hypotheses

Evaluation

Component

Evaluation Question

Evaluation Hypotheses

Process

How did beneficiaries utilize

covered health services?

Enrollees will utilize family planning services

and/or family planning related services.

Process

Do beneficiaries maintain coverage

long-term (12 months or more)?

Beneficiaries will maintain coverage for one

or more 12 month enrollment period

Process

Does the demonstration increase

the use of more effective

contraceptive methods among FPO

beneficiaries?

Beneficiaries will have a higher rate of using

more effective contraceptive methods

compared to other members of Medicaid

beneficiaries.

Outcome/Impact

Does the demonstration improve

health outcomes?

Health outcomes will improve as a result of

the demonstration.

Outcome/Impact

Does the demonstration decrease

the number of unintended

pregnancies?

The number of women reporting unintended

pregnancy will decrease.

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Methodology

Data

The data sources for this evaluation come from the Washington State Department of Health (DOH) and the

Health Care Authority (HCA). The sources include; 1) Vital Statistical birth certificate data, 2) Pregnancy Risk

Assessment Monitoring System (PRAMS) survey data, 3) Medicaid eligibility, enrollment, and claims files. Each

data source is described below.

Data for the evaluation are based on eligibility, birth certificates, and linked claims file with vital records also

known as the First Steps Database (FSDB). Claims and eligibility data are available for all Medicaid clients.

Medicaid eligibility, enrollment, and claims data Washington State’s Medicaid

Management Information System, ProviderOne, contains eligibility recipient aid category (RAC) codes, the

eligibility begin and end dates, which are used to derive enrollment and participation in the program.

ProviderOne also contains enrollment data for all clients deemed eligible for the Program, including date of

birth, race/ethnicity, county of residence, and other demographics. Finally, ProviderOne also contains claims

data, a record for every claim submitted for reimbursement. Data elements in the claim files include date of

service, program code, procedures and diagnosis used to derive program participation measures. For all FPO

eligible clients, the FSDB staff obtains a service history for appropriate time periods for each client. ProviderOne

services history data are used to describe the types of FP services provided. ProviderOne is updated monthly.

First Steps Database (birth certificates linked to Medicaid clients): All

Washington birth certificates are linked at the individual level to Medicaid claims and eligibility history. FSDB

begins with births in August 1988 and currently contains linked birth certificates through 2021. The annual

unduplicated count of FPO eligible clients is linked to the FSDB by ProviderOne ID. The First Steps Database is

created biannually.

Pregnancy Risk Assessment Monitoring System (PRAMS) survey: To evaluate

the program goal of reducing the number of unintended pregnancies, Washington will rely on the PRAMS survey

to describe unintended pregnancy rates. PRAMS is a surveillance survey by the Centers for Disease Control and

Prevention (CDC) developed to report maternal attitudes and experiences before, during, and shortly after

pregnancy. As of 2023, forty-six states participated in PRAMS, covering approximately 81 percent of all live births

in the United States. These data can be used to identify groups of women and infants at high risk for health

problems, monitor changes in health status, and to measure progress towards goals in improving the health of

mothers and infants. PRAMS data allows evaluators to compare state-specific rates against national trends and

Healthy People 2030 goals.

Methods

Evaluating the impact of FPO on key outcomes is complicated by the longevity of the waiver and lack of

experimental comparison. The original evaluation design proposed to utilize a post-only assessment with a

simulated comparison group created using propensity score methodology. However, the differences between

FPO and Medicaid population were difficult to statistically match given enrollment and utilization shocks from

COVID-19, Public Health Emergency extended coverage, and impacts from a new state program, After Pregnancy

Coverage (APC).

The original evaluation design stipulated that if a comparison group could not be constructed via propensity

score methodology, then descriptive statistics would be used to evaluate process and outcome measures over

time for the FPO beneficiaries only. Each measure was stratified by each waiver group summarized in Table 1.

Moreover, given most program enrollees identify as women, we excluded some sub-populations (e.g., males,

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teens, and domestic violence victims) due to data availability and small sample sizes which would lead to less

power to detect statistical differences.

The timeframe for the post-only period will begin when the current demonstration period begins on 7/1/2018

and ends when the current demonstration period ends on 06/30/2023.

FPO Waiver Study Populations

The study examines and compares three target populations eligible for Family Planning Only (FPO) services

separated based on income level or pregnancy status: Family Planning Only Waiver groups were identified by

the RAC codes (1097 (FPO Pregnancy-Related), 1099 (FPO Lower Income), and 1100 (FPO Higher Income)). While

Table 1 describes two waiver groups, we further delineated the non-pregnancy-related Family Planning Only

group into a Lower Income group with family incomes greater than 133 percent and less than or equal to 185

percent FPL and a Higher Income group with family incomes greater than 185 percent and less than or equal to

260 percent FPL. This report examines and compares each waiver group separately given that these waiver

groups have different waiver enrollment eligibility criteria, income eligibility, and coverage periods. Most

analyses were focused on clients identifying as women. Due to small numbers, clients identifying as men were

excluded from subsequent analyses and described in a separate section.

Definitions and Measures

Full-scope Medicaid: Full-scope Medicaid provides full health care coverage such as early and periodic

screening, diagnostic, and treatment services, maternity and newborn care, and mental health services. States

have been required to include family planning services in their Medicaid programs.

Disenrollment: A gap in Medicaid enrollment of more than four months.

Enrollees: Individuals enrolled in the demonstration for the specified waiver period.

Family planning services: Women and men who are waiver enrollees are eligible to receive an annual

comprehensive family planning preventive visit, FDA-approved birth control methods, and a narrow range of

family planning services that help clients use their contraception safely and effectively.

Family planning-related services: Includes screening for gonorrhea and chlamydia for women ages 13 through

25 and cervical cancer screening.

Participants or Utilizers: Individuals who obtain one or more covered family planning service through the

demonstration waiver.

Relative Risk Ratio: The risk of one subgroup in comparison to the risk of all other subgroups to experience any

disproportionate outcome. A Relative Risk Ratio of 1 means a subgroup faces no disproportionality and less than

1 means underrepresentation of a subgroup.

Retention: A client continuously enrolled or experiencing a gap in eligibility of no more than four months.

Domestic Violence: Domestic violence was flagged based on domestic violence identified in the comprehensive

evaluation, participation in the address confidentiality program, or being granted permission not to cooperate

with Division of Child Support due to domestic violence as recorded in ACES; or based on domestic violence

arrests or convictions of the client.

URBAN RURAL COUNTY CLASSIFICATION

• Rural Counties: Adams, Asotin, Columbia, Ferry, Garfield, Jefferson, Klickitat, Lincoln, Okanogan, Pacific, Pend

Oreille, San Juan, Skamania, Stevens, Wahkiakum.

• Large Town Counties: Chelan, Clallam, Douglas, Grant, Grays Harbor, Island, Kittitas, Lewis, Mason, Whitman.

• Urban–Medium and Low-Density Counties: Benton, Cowlitz, Franklin, Skagit, Walla Walla, Whatcom, Yakima.

• Urban–High Density Counties: Clark, King, Kitsap, Pierce, Snohomish, Spokane, Thurston.

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MATERNAL/CHILD OUTCOME VARIABLES

• Interpregnancy Interval (IPI): A measure of birth spacing operationalized as the time (in months) elapsed

between the women’s last delivery and the conception of the next pregnancy.

• Low Birth Weight: Low birth weight refers to infants born weighing less than 2,500 grams. Birth weight was

collected as a continuous variable on the birth certificate. For analysis purposes, low birth weight was treated

as a dichotomous variable. Birth weight on the second birth per client was used to analyze the effect of the

waiver on birth weight.

• Preterm Birth: To determine whether an infant was considered preterm, the clinical estimate of weeks

gestation on the birth certificate was used. Infants born at less than 37 weeks gestation were considered

preterm. While weeks gestation is a continuous variable, it was dichotomized for analyses. Preterm birth data

from the second birth was used in this evaluation.

CONTRACEPTIVE METHODS

• Most Effective (>99 percent): Sterilization, contraceptive implants, IUD

• Moderately Effective (88-94 percent): Injectables, oral pills, patch, vaginal ring, diaphragm

• Least Effective (<82 percent): Female condom, cervical cap, sponge, fertility awareness-based methods,

spermicide

• Emergency Contraception: Emergency contraceptive pills or copper IUD after unprotected intercourse

Quantitative Methods

Monotonic Trend Analysis

There are several statistical tests available to identify and quantify monotonic trends. Statistical trend analysis is

a hypothesis testing process. The null hypothesis is that there is no trend, and each test has its own parameters

for accepting or rejecting the null hypothesis given assumptions of normal distribution and sample size. We

chose to test for trends using Mann-Kendall given that it is a nonparametric test providing higher statistical

power in cases of nonnormality, is robust against outliers, large data gaps, and some autocorrelation as clients

and their family planning choices are not independent over time. This test evaluates whether values tend to

increase or decrease over time and whether the trend in either direction is statistically significant, but does not

assess the magnitude of change. Alpha was set to p < 0.05. Statistical analysis was performed using SAS

software, version 9.

For objective #1 (Ensure access to and utilization of family planning and/or family planning-related services for

individuals not otherwise eligible for Medicaid), we applied descriptive methods of frequency, proportions, and

test for trend to demonstrate service utilization of FPO for all the service utilization measures specified below:

• Proportion of beneficiaries who had a family planning or family planning related service encounter in

each year of the demonstration.

• Proportion of family planning services utilized.

• Proportion of female beneficiaries who utilized any contraceptive in each year of the demonstration.

• Proportion of female beneficiaries who utilized long-acting reversible contraceptives in each year of the

demonstration.

• Proportion of beneficiaries tested for any sexually transmitted disease (by STD).

• Proportion of female beneficiaries who obtained a cervical cancer screening.

To measure: 1) whether the beneficiaries maintain coverage long term, i.e., continues enrollment of 10 or 12

months or more, and 2) whether there is a re-enrollment for at least the second spell of coverage three years

prior to and three years post the current enrollment year, the eligibility start and end month over time was used

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to determine whether Program clients were eligible for re-enrollment and applied, were ineligible for re-

enrollment (e.g., due to sterilization), or had become eligible for another federal/state program.

For objective #2 (Improve or maintain health outcomes for the waiver population as a result of access to family

planning and family planning-related services), For the outcome measures of birth span, low birth weight and

premature babies, the differences in proportions of the outcomes will be tested at an annual basis. We will also

calculate the proportions of these outcome measures at a biannual basis and therefore, Cochran-Armitage test

for trend can be conducted when applicable.

For objective #3 (Reduce the number of unintended pregnancies in the waiver population), pregnancy intentions

on the PRAMS survey are obtained by asking respondents to think back to the time just before their pregnancy

and to recall how they felt about becoming pregnant at that time. The pregnancy intention question is a part of

the “core” set of questions, asked in each participating state’s uniform set of questions. The PRAMS

questionnaire is mailed to women who have had a recent live birth (usually within 2 to 6 months after delivery),

with each state’s sample drawn from vital records, and including oversampling by specific characteristics to

create annual, representative data at the state level of all women delivering in that year.

Respondents may choose one of five response options: ‘I wanted to be pregnant sooner’, ‘I wanted to be

pregnant later’, ‘I wanted to be pregnant then’, ‘I didn’t want to be pregnant then or any time in the future’, or ‘I

wasn’t sure what I wanted’. Beginning in 2012, the last response, ‘I wasn’t sure what I wanted’ was added to the

responses. As a result, unintended pregnancy rates computed from 2013 onward are not directly comparable to

those prior to 2013.

Traditionally, respondents who select, ‘I didn’t want to be pregnant then or any time in the future’ are defined as

unwanted pregnancies. To evaluate the program goal of reducing the number of unintended pregnancies,

Washington will rely on the PRAMS survey to describe unintended pregnancy rates. The original evaluation

design proposed to link PRAMS survey results to Medicaid and FPO clients so the survey results can be reported

for the waiver population of the family planning waiver. However, given impacts from COVID-19, the Public

Health Emergency extended coverage to any FPO Pregnancy-Related potential population, and

implementation of a state program, After Pregnancy Coverage (APC), we proposed to report on state-wide rates

compared to other participating PRAMS locations.

Methodological and Study Limitations

This section provides sufficient information for discerning the strengths and weaknesses of the study design,

data sources/collection, and analyses.

There were four main limitations for this study. First, we can only account for contraceptive methods obtained

via paid claims through Washington State’s Medicaid program and/or the Family Planning Waiver. Any

contraceptive methods or medical administrative claims paid by a private insurer or out-of-pocket were not

included in these analyses.

Second, we can only account for family planning services obtained via Washington State’s Medicaid program

and/or the Family Planning Waiver. Washington State provides a variety of programs and options for women

and men to receive family planning services throughout their reproductive years, so the utilization in one

program may impact utilization in another program. For example, pregnant women at or below 198 percent FPL

are covered by Medicaid and receive 60-days post pregnancy healthcare which includes contraception. FPO

Pregnancy-Related utilization in the Family Planning Waiver may be misleading given the receipt of services

post-pregnancy.

Third, while administrative data provide the means to identify and describe utilization, it is limited in providing

information regarding sexual behavior and/or pregnancy intention. Additionally, claims data were used to

analyze contraceptive methods prescribed, however this cannot measure adherence. As a result, any calculation

intended to measure medication adherence analysis might overestimate the true adherence rate because it

assumes clients took all medication as intended (13).

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Finally, the fourth limitation, the intended study design proposed to simulate a comparison group using

propensity score methodology with the aim to balance FPO waiver groups (especially, the FPO Pregnancy-

Related waiver group) and comparable Medicaid program on observed characteristics to obtain less biased

estimates of any waiver treatment effects. There are several federal/state programs in Washington State that

offer family planning methods and services and the intent was to match client characteristics, social services

and medical program utilization. However, given impacts from the Public Health Emergency and

implementation of a state program, After Pregnancy Coverage (APC) – both of which extend full-scope coverage

to post-pregnancy clients – reduced the FPO Pregnancy-Related potential population and data were not

available to match on FPO Pregnancy-Related waiver clients that decided to enroll/re-enroll and those that

maintain other full-scope coverage.

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Results

The COVID-19 quarantine, associated healthcare access restrictions, and

subsequent Public Health Emergency (PHE) eroded enrollment and

participation gains from the pre-pandemic period.

During the most recent waiver period, there have been state and federal policy changes that have impacted

enrollment demographics and participation (Figure 1). On January 21, 2020, the Centers for Disease Control and

Prevention (CDC) confirmed the first case of COVID-19 in Washington State. Two months later, Governor Inslee

issued ‘Stay Home, Stay Safe’ proclamation starting the Public Health Emergency.

Peak enrollment occurred in October 2018. Enrollment declined 72 percent from March 2020 to December 2020

as recently pregnant clients were eligible to maintain full-scope Medicaid coverage and explaining the

decreased enrollment of this waiver group.

Utilization (or participation) rates also changed with COVID-19 quarantine restrictions. Figure 1 shows month-to-

month utilization rates for family planning services. Before COVID-19 quarantine restrictions, the participation

was about 6 percent, followed by a small decrease during the quarantine restriction, and an increase in

December 2020.

FIGURE 1

Impact of COVID-19 on Washington State’s Family Planning Demonstration Caseload

7,628

3,021

5.9%

5.6%

10%

20%

30%

40%

50%

60%

70%

80%

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J

DECEMBER 2020

 COVID-19 vaccine doses to

frontline medical workers

MARCH 2020

 ‘Stay Home, Stay Safe’- COVID-19 Governor’s

Order - Start of Public Health Emergency

Monthly FPO Waiver

Caseload

Utilization

2018

2019

2020

2021

2022

JANUARY 2020

 CDC confirms first

US case of COVID-19

in Washington State

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Enrollment and Participation by Waiver Group

As discussed in the previous section, the COVID-19 global pandemic and quarantine impacted overall caseload

and Family Planning Waiver group demographics. Figure 2 shows the proportion of participation for each waiver

group to total participants for each demonstration year to provide an overview of changes during the current

waiver period. The proportion of waiver participants using services increased at the same rate for both FPO

Lower Income and FPO High Income waiver groups, while FPO Pregnancy-Related participation decreased

(Figure 2). This finding is also seen in the month-to-month changes in Figure 3.

FIGURE 2

Participation of Family Planning and Family Planning-Related Services

By Waiver Groups (Women Only)

2018 2019 2020 2021

FPO Pregnancy-Related

FPO Lower Income

FPO Higher Income

29%

21%

32%

13%

57%

46%

To determine whether COVID-19 impacted disproportionality related to family planning service participation,

risk ratios were calculated for each waiver group by demonstration year, for age, race/ethnicity, and urban/rural

composition (Tables not shown).

• Younger aged clients were more likely to participate in family planning waiver services than older aged

clients, regardless of waiver group.

• Some racial/ethnic groups in the FPO Lower Income waiver group were underrepresented in family

planning waiver participation which further declined over the waiver period.

• Clients living in Urban – Medium and Low-density counties were more likely to participate in family

planning waiver services than Urban – High density, regardless of waiver group.

Figure 3 is similar to Figure 1 but shows caseload and participation rates month-to-month for each waiver group

over the current demonstration period. Understanding the changes in caseload is important because caseload

(i.e., Medicaid clients who are enrolled in the program) is used as a denominator for one process measure, while

the remaining process measures use participation (i.e., Medicaid clients who are both enrolled and using

services in the program) as the denominator.

• Despite the extension of full-scope Medicaid benefits to recently pregnant clients, FPO Pregnancy-Related

waiver group had the highest enrollment of any waiver group during the demonstration period, yet the

smallest participation of any waiver group.

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FIGURE 3

Impact of COVID-19 on Washington State’s Family Planning Demonstration Caseload

Caseloads and Participation By Waiver Group (Women Only)

FPO Pregnancy-Related

4,978

1,402

15%

30%

45%

3,000

6,000

9,000

2018 2019 2020 2021 2022

Participation

COVID-19

Monthly FPO Waiver

Caseload

FPO Lower Income

16%

1,841

1,151

15%

30%

45%

3,000

6,000

9,000

2018 2019 2020 2021 2022

Participation

Monthly FPO Waiver

Caseload

COVID-19

FPO Higher Income

20%

694

15%

30%

45%

3,000

6,000

9,000

2018 2019 2020 2021 2022

Participation

10%

433

Monthly FPO Waiver

Caseload

COVID-19

Family Planning Services

The remainder of this report describes trends in family planning process and outcome measures based on the

waiver groups defined in the previous section. Process measures describe the utilization of family planning and

family planning-related services traditionally associated with favorable maternal and child health outcomes.

Given the impacts of COVID-19 on the Family Planning Waiver group enrollment and participation, we

anticipated changes to process measures.

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EVALUATION QUESTION

How did Family Planning Waiver clients utilize services?

Any Contraceptives Used by Female Participants

We measured any contraceptive use by reporting clients in a waiver group who obtained any contraceptive

method out of the total number of participating clients in the same waiver group. Figure 4 shows the annual

percentages of any contraceptive use, by waiver group.

· The percentage of participants accessing any contraceptive method remained higher among clients in the

FPO Lower Income and FPO Higher Income waiver groups compared to FPO Pregnancy-Related waiver

group.

· There was a significant trend in the decreased proportion of participating clients accessing any

contraceptive method for all waiver groups (p<0.05).

FIGURE 4

Any Contraceptive Used by Waiver Group

By Waiver Groups (Women Only)

FPO Pregnancy-Related

FPO Lower Income

FPO Higher Income

60%

59%

48%

46%

2018

2019

2020

2021

85%

77%

69%

67%

2018

2019

2020

2021

86%

79%

73%

70%

2018

2019

2020

2021

Long-Acting Reversible Contraceptives (LARC)

Long-acting reversible contraception (LARC), such as use of implants or intrauterine devices, is highly effective at

preventing unintended pregnancy (8). We measured LARC utilization by reporting the number of women with

LARC methods used in a year out of the total number of participants in each group (Figure 5).

· Utilization of a LARC method was highest among the FPO Pregnancy-Related waiver group compared to

clients in other waiver groups.

· The percentage of both FPO Pregnancy-Related and FPO Higher Income LARC users demonstrated

modest increases from the DY2018 to the DY2021 cohort, while FPO Lower Income waiver group had the

highest proportion of LARC utilizers in DY2020, then declined by the next year. However, none of these

trends were statistically significant.

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FIGURE 5

LARC use by Waiver Group (Women Only)

FPO Pregnancy-Related

FPO Lower Income

FPO Higher Income

28%

27%

23%

25%

2018

2019

2020

2021

21%

19%

23%

2018

2019

2020

2021

20%

19%

26%

19%

2018

2019

2020

2021

Family Planning-Related Services

CMS defines family planning-related services as “medical diagnosis and treatment services that are provided

pursuant to a family planning service in a family planning setting” (10), but states vary in their coverage of family

planning-related services. Washington State family planning-related services include testing for sexually

transmitted infections specifically related to the effective and safe use of the chosen contraceptive and cervical

cancer screening.

Sexual Transmitted Infections (STI) Screening and Testing

All women in the target groups ages 13–25 receive screening and all women receive testing when symptoms or

exposure are reported. Men are limited to testing only when exposure or symptoms are reported. Figure 6 shows

the number of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) screens and tests provided to clients in

a year out of the total number of participants in each waiver group.

· FPO Lower Income waiver group, with the greatest proportion of teens aged 13-18 years, continued to

have the greatest percentage of STI screens/tests in DY2018, which declined in DY2019 and DY2020, but

increased to 38 percent in DY2021. There was a significant trend in the decreased rate of participating FPO

Lower Income waiver group accessing any STI screens/test (p<0.05).

· There was no significant trend in the rate of STI Screenings in the FPO Higher Income group.

· STI screenings for FPO Pregnancy-Related clients demonstrated no statistical trend and remained

relatively the same from 8 percent in DY2018 to 7 percent in DY2021.

FIGURE 6

STI Screenings/tests by Waiver Group Female Participants

FPO Pregnancy-Related

FPO Lower Income

FPO Higher Income

2018

2019

2020

2021

39%

29%

28%

39%

2018

2019

2020

2021

44%

41%

34%

38%

2018

2019

2020

2021

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Cervical Cancer Screening

Providers must follow nationally recognized clinical guidelines for cervical cancer screening, which recommend

screenings every 3 to 5 years depending on age and exposure risk. We measured cervical cancer screenings by

reporting the number of cervical cancer screens in a year out of the total number of participants in each waiver

group. Figure 7 shows the percentage of females who received cervical cancer screening using cervical cytology

(Pap test) and/or human papilloma (HPV) testing.

· FPO Lower Income waiver group had the lowest rates of cervical cancer screening. However, in DY2018, 65

percent of participants in the group were under 21 years. Given this age category is not included under the

cervical cancer screening age recommendations (11,12) it makes sense there would be less screening in this

waiver group.

· While the majority of FPO Higher Income participants were over 21 years, there was a statistically

significant trend in cervical cancer screenings (p < 0.05) which declined from 8 percent in DY2018 to 4

percent in DY2021.

FIGURE 7

Cervical Cancer Screening by Waiver Group Female Participants

FPO Pregnancy-Related

FPO Lower Income

FPO Higher Income

2018

2019

2020

2021

2018

2019

2020

2021

2018

2019

2020

2021

Disenrollment and Retention

As mentioned in Table 1, Washington State’s Family Planning Waiver has different coverage periods for different

waiver groups. FPO Pregnancy-Related offers an additional 10-months of coverage following the standard

Medicaid 60-days post pregnancy coverage. However, once clients in FPO Pregnancy-Related complete 10-

months, they can reapply as a Family Planning Only client if they meet eligibility requirements. FPO Lower and

Higher Income eligible clients have 12-months of coverage, but can reapply if they continue to meet eligibility

requirements.

TABLE 2

Annual Disenrollment and Retention

For all clients by demonstration year

Reason for Disenrollment

2018

2019

2020

2021

Sterilization

357

3.6

287

2.9

113

2.3

4.7

Eligible for full benefits due to pregnancy

673

6.8

724

7.4

384

7.7

214

21.5

Eligible for full benefits

1,144

11.6

1,495

15.3

593

11.9

298

29.9

Re-enrolled

168

1.7

121

1.2

0.7

1.6

Did not renew

7,210

73.3

6,865

70.1

2,960

59.6

205

20.6

Eligible for other state-funded program

285

2.9

298

3.0

879

17.7

216

21.7

Total Disenrollment Number

9,837

9,790

4,965

996

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EVALUATION QUESTION

Do beneficiaries maintain coverage long-term (12-months or more)?

Disenrollment and retention are important to monitor given that inconsistent use of contraception is a cause of

nearly half of unintended pregnancies (8). As a result of Medicaid expansion and health care reform, the pattern

of disenrollment and retention dramatically changed in 2013. However, over the past four demonstration years

(2018 through 2021 are years with complete data), patterns have been impacted indirectly by changing client

eligibility due to COVID-19. Over this waiver period, the percentage of clients eligible for full benefits increased

from almost 12 percent in DY2020 to almost 30 percent in DY2021. Similarly, the percentage of clients eligible for

other state-funded program increased from 3 percent in DY2019 to almost 18 percent in DY2020.

Special Population

Any contraceptives used by Male Participants

National studies have estimated that 60 percent of men were in need of family planning, especially young and

unmarried men (9). However, less than two percent of all enrollees (or participants) in the FPO groups in

Washington are clients identifying as male. Vasectomies are the most popular method of contraception for these

men, followed by male condoms. However, once sterilized, clients are no longer eligible for waiver services, such

as family planning-related services (e.g., screenings for sexually transmitted infections).

Maternal and Child Health Outcomes

EVALUATION QUESTION

Does the Family Planning Waiver improve maternal and child health outcomes?

Access to family planning may impact maternal and child health outcomes by delaying pregnancies that occur

too early or too late in a person’s life and spacing the time between pregnancies. We will assess whether Family

Planning Waiver services impacted maternal and child health outcomes using three measures: 1)

Interpregnancy interval (i.e., time from the birth of baby to the conception of another baby) may be extended

by the correct use of effective contraceptive methods. Interpregnancy intervals of 18 months or longer are ideal

and are strongly associated with a decreased risk of low birth weight, preterm birth, and/or small for gestational

age (13), 2) Low birth weight, and 3) preterm birth. These last two measures are indirect since they are

affected by interpregnancy intervals, but both measures are also influenced by maternal health conditions and

other socioeconomic disparities (14,15).

Given the decreased enrollment and participation among the FPO Pregnancy-Related waiver group, the

interim evaluation report will not include these findings as we continue to assess any systematic differences

between FPO Pregnancy-Related enrollees and participants, eligible FPO Pregnancy-Related clients who

maintained full-scope Medicaid coverage due the Public Health Emergency, and eligible FPO Pregnancy-

Related clients participating in After Pregnancy Care(APC), a new state program extending postpartum care

which was implemented in June 2022.

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Unintended Pregnancies

EVALUATION QUESTION

Does the Family Planning Waiver decrease the number of unintended pregnancies?

Results from Washington State Pregnancy Risk Assessment Monitoring System (PRAMS) are used to assess

pregnancy intent. Survey respondents are asked to think back before their recent pregnancy and report whether

they had wanted to become pregnant at that time, sooner, later, or not at all.

Pregnancies that occur too soon are classified as mistimed those that are not wanted at all are labeled

unwanted, and those two categories together form the unintended group. Pregnancies that occur too late or “at

about the right time” are considered intended. Based on analysis of previous year’ response breakdowns, the

unsure responses have been grouped as part of the unintended category. Figure 8 details the proportion of

Washington births that were unintended, starting in 2016 and compares annual percentages to all selected

PRAMS sites that met the required 55% response rate threshold. The proportion of Washington State births

classified as unintended have declined over the years in the current waiver period and are consistently lower

than the national comparison.

FIGURE 8

Proportion of Washington State Births that were Unintended

Pregnancy Risk Assessment Monitoring Program (PRAMS) results from 2016-2020

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Discussion

As part of a section 1115 demonstration authority, states must conduct an evaluation to inform policy decisions

as per 42 CFR 431.424. Given the ACA mandate requiring preventative well-women visits, some states

discontinued pursuing Family Planning waiver renewals assuming clients would be able to secure family

planning services through comprehensive Medicaid or a Marketplace plan (10). However, the results of the

interim evaluation suggest Washington State’s Family Planning Demonstration Waiver continues to have an

important role for low-income women not eligible for Medicaid who are seeking high-quality, confidential family

planning services.

More details on efforts to improve the use of available family planning services in Washington State:

• As of June 2022, Washington State has elected to extend postpartum coverage from 60 days to 12 months

(After Pregnancy Coverage). This change means that postpartum clients are no longer

automatically/passively enrolled in FPO Pregnancy-Related.

• Beginning in DY2019, individuals enrolled in any FPO waiver group could see any contracted Medicaid

provider for family planning services, rather than the more limited pool of qualified Take Charge providers.

• Previous research examining LARC use among full-scope Medicaid compared to Family Planning Waiver

participants found that the percentage of Family Planning Waiver LARC users was twice that of full-scope

Medicaid clients for all women aged 15-44 at risk of unintended pregnancy (11). HCA increased

reimbursement rates to providers regarding LARC insertion or implantation in 2015 and this was associated

with increasing LARC use (12).

• Efforts were made to increase ease of obtaining consistent supplies of oral contraceptives, the most popular

form of family planning method among FPO Pregnancy-Related and FPO (Higher and Lower Income)

clients. However, past research has shown that dispensing a one-year supply of oral contraceptives was not

implemented as broadly as intended (12).

• Another area of needed improvement is increasing utilization among men. As mentioned previously,

research from the National Survey of Family Growth showed that 60 percent of men aged 15-44 years were in

need of family planning (4). Family planning services offered through Washington State’s Demonstration

Waiver include an annual counseling session for reducing the risk of unintended pregnancy, use of condoms,

spermicides, and vasectomies, and STI screenings if experiencing symptoms.

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Lessons Learned and Recommendations

The final evaluation report will extend analyses to Program demonstration year 2022 and attempt to reduce

confounding from any state legislative or federal changes impacting the Program since the start of this waiver

period. As mentioned, the feasibility to evaluate maternal-child health outcome measures have been challenged

by the reduction of FPO Pregnancy-Related enrollees due to Public Health Emergency extension of full-scope

Medicaid and/or participation in After Pregnancy Coverage.

Given these state policy changes, we recommend the following changes to allow for more meaningful and

actionable results:

• Adding process measures regarding equity and application barriers/challenges to evaluate access

to family planning and family planning-related services.

o Process measures aimed to measure equitable access to contraceptive methods by

race/ethnicity, age, sexual orientation, gender identity, and expression (SOGIE), and

urbanicity. In Washington State, COVID-19 and related quarantine restrictions, impacted

family planning disproportionality service participation. For example, during the current

waiver period, some racial/ethnic groups in the FPO Lower Income waiver group were

underrepresented in family planning waiver participation which were further exacerbated over

the waiver period. Additionally, clients living in Urban - Medium and Low - density counties

were more likely to participate in family planning waiver services than Urban – High density,

regardless of waiver group.

o Process measures aimed at measuring barriers/challenges in the application process. Any

program enrollment and re-enrollment begins with the application process (e.g., client

language preference, timing and receipt of reminder notifications, determining and meeting

eligibility criteria, support documents needed, whether client needed assistance completing

an application, time from starting to submitting an application). While the evaluation showed

a decrease in the proportion of FPO Waiver eligibility clients that did not renew, this change

was due to clients being eligible for other programs with full-scope coverage. Adding

additional process evaluation measures regarding the application process could inform

client/provider outreach activities, reduce lapses in service, and increase continuity of

contraceptive method utilization.

• Adding qualitative/mixed-methods analysis for sub-population(s) of interest.

o Incorporating client perspectives on populations of interest e.g., teens, intimate partner

violence victims, and clients identified as male. Between 2012 and 2021, teen births have

declined 63 percent in Washington State. Despite this decline, 95 percent of teen births were

Medicaid-paid highlighting a continued need for confidential family planning services. Results

from this interim evaluation showed that younger aged clients were more likely to participate

in family planning waiver services than older aged clients, regardless of waiver group, but were

more likely to use less effective methods (e.g., emergency contraceptive pill). However, due to

data availability and small sample sizes, these sub-populations are often excluded from

quantitative analysis. Therefore, alternative methods (e.g., focus group discussions) involving

providers/Community Health Workers might be an effective approach to supplement future

evaluation findings.

• Incorporate evaluation measures that focus on patient experience of contraceptive care.

o Relying on family planning utilization measures are imperfect proxies of quality and access.

Additionally, evaluation measures that focus on only one contraceptive method (e.g., LARCs)

may lead to client coercion and assumptions that ‘one-size fits all’ even though research shows

that contraceptive method choice is highly preference-sensitive and influenced by availability,

costs, life stage, and counseling.

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References

(1) Washington Family Planning Only Program-State Application-2017 Extension (November 22, 2017). Centers for

Medicare & Medicaid Services. Retrieved from https://www.medicaid.gov/medicaid/section-1115-

demo/demonstration-and-waiver-list/?entry=8632.

(2) Secura, G. (2013). Long-acting reversible contraception: a practical solution to reduce unintended pregnancy.

Minerva Ginecologica. 65(3): 271-277.

(3) Marcell, A.V., Gibbs, S.E., Choiriyyah, I., Sonenstein, F.L., Astone, N.M., Pleck, J.H., & Dariotis, J.K. (2016).

National needs of family planning among US men aged 15 to 44 years. Journal of the American Public Health

Association. 106(4): 733-739.

(4) CMS, HHS. (July 2, 2010). Family Planning Services option and new benefit rules for benchmark plans. SMDL

#10-013. https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10013.pdf.

(5) US Preventive Services Task Force. Final recommendation statement, cervical cancer: screening. Rockville,

MD: US Preventive Services Task Force; 2012. https://www.uspreventiveservicestaskforce.org/Page/

Document/RecommendationStatementFinal/cervical-cancer-screening.

(6) Committee on Practice Bulletins—gynecology: https://www.acog.org/Clinical-Guidance-and-

Publications/Practice-Advisories/Practice-Advisory-Cervical-Cancer-Screening-Update (August 21,2018)

(7) Conde-Agudelo, A., Rosas-Bermudez, A., Kafury-Goeta, A.C., (2006). Birth spacing and risk of adverse perinatal

outcomes: a meta-analysis. JAMA. 295(15): 1809-1823.

(8) Wilcox, A.J. (2001). On the importance—and unimportance—of birthweight. International Journal of

Epidemiology. 30(6), 1233-1241.

(9) Blumenshine, P., Egerter, S., Barclay, C.J., Cubbin, C., Braverman, P.A. (2010). Socioeconomic disparities in

adverse birth outcomes: a systematic review. American Journal of Preventive Medicine. 39(3): 263-272.

(10) Ranji U, Bair Y, Salganicoff A. Medicaid and Family Planning: Background and Implications of the ACA. Kaiser

Family Foundation. February 2016. Available at http://files.kff.org/attachment/issue-brief-medicaid-and-

family-planning-background-and-implications-of-the-aca.

(11) Xing, J., Lyons, D., Fan, Z., Glenn, A., & Felver, B. (2019). Improving Women’s Access to Long-Acting Reversible

Contraception: Role of Medicaid Reimbursement Policy Change. DSHS Research and Data Analysis, Olympia, WA.

(12) Fan, Z., Lyons, D., Felver, B., & Glenn, A. (2018). The Effect of Dispensing One-Year Supply of Oral Contraceptive

Pills. DSHS Research and Data Analysis, Olympia, WA.

(13) Yeaw, J., Benner, J., Walt, J., Sian, S., Smith, D. (2009). Comparing adherence and persistence across 6 chronic

medication classes. Journal of Managed Care Pharmacy. 15(9), 728-740.