Among the 50 states, 38 (76%) had state-based policies or indirectly referenced policies (Table 2). Of those policies, three (8%) were described by indirect references. Among state-based policies, all identified Medicaid directly, and two (5%) also identified non-Medicaid plans or private plans as payors for reimbursable services.

More than two-thirds of states had policies specifically referencing immediate postpartum LARC, and all policies identified Medicaid as the payor, with very few denoting other insurers. Most states with immediate postpartum LARC policies allowed for billing of both insertion procedures and device costs separate from the global obstetric fee, although distinct differences among who was authorized to bill were observed. Although most of the states allowing billing for insertion procedures authorized the provider to bill for costs, when billing for the cost of the device, most often hospitals/facilities were authorized to bill rather than providers. Most state policies included language on the mechanisms for billing of device costs, whereas only one-half of state policies included language on billing of insertion procedures―and among those, the majority used inpatient billing. This finding highlights an opportunity for states to further examine whether payment methodologies fully capture reimbursement for procedures necessary for providing LARC. Overall, our results indicate that state policies for the reimbursement of immediate postpartum LARC insertion procedures and device costs vary substantially.

The 2016 CMS bulletin recommends payment strategies such as separating reimbursement from the global obstetric fee and removing other logistical and administrative barriers including acquisition and supply costs or other preauthorization requirements (CMS, 2016). Such payment strategies may offer opportunity to reimburse providers and facilities for device prices and procedure fees not included in the global obstetric fee, because the bundled fee may be inadequate for the provision of immediate postpartum LARC. However, the current literature on the benefits of bundled payments or global fees for medical services focuses on cost savings and improved health outcomes―for instance, in the surgery literature, bundled services generate cost savings and improve coordination of care without compromising patient outcomes (Agarwal, Liao, Gupta, & Navathe, 2020; Dietz et al., 2019; Glickman, Dinh, & Navathe, 2018). Similar evidence on the effectiveness of the global obstetric fee was not identified in the published literature, and this absence limits this assessment of reimbursement for evidence-based procedures and services associated with quality labor and delivery care. In fact, bundling payments for pregnancy and postpartum services may inadvertently impact provision of other evidence-based care, such as developing a plan for the postpartum visit, an effort that may require multiple interactions between women and health care providers (American College of Obstetricians & Gynecologists, 2018). One reimbursement fee may affect the number of ongoing patient–provider interactions. In effect, although not assessed in the review, adequate health system and provider reimbursement may facilitate provision of quality care, supporting clinical guidelines and patient needs and preferences (American College of Obstetricians and Gynecologists, 2016). More research on the impacts of different payment methodologies could build the evidence on the costs and benefits of bundled versus enhanced, separate, or supplemental reimbursement.

Within states, challenges to implementation of reimbursement strategies include conveying the economic advantages to health systems (Moniz et al., 2015), recruiting and leveraging provider champions (Kroelinger et al., 2019), and promoting patient benefits and provider awareness (Moniz et al., 2015), while limiting the out-of-pocket costs for patients (Sonfield, Tapales, Jones, & Finer, 2015). Certain hospital systems, such as university or teaching hospitals, may be better equipped to address reimbursement challenges (Holden et al., 2018), such as efficient claims processing, maintenance of reimbursement rates, or inpatient billing (Moniz et al., 2015), because processes may be clearly defined that allow for hospital administration support (Moniz et al., 2016) and increased provider knowledge on reimbursement mechanisms (Hofler et al., 2017; Holden et al., 2018; Moniz et al., 2015). In piloting methods for reimbursement, facilities may develop a step-by-step approach to implementing immediate postpartum LARC programs that address finance and billing process challenges (Hofler et al., 2017) and logistical barriers to same-day insertion (Castleberry, Stark, Schulkin, & Grossman, 2019). Such a stepped approach may include partnering with facility pharmacies to ensure stocking of devices, then working with information technology departments to develop a billing and reimbursement system for both insertion procedures and device costs (Hofler et al., 2017). For example, Brown, Greenfield, and Rapkin (2020) describe how one state developed a two-phase pilot with the first phase consisting of stakeholder engagement and protocol development, and the second phase focused on implementation through partnership with a Perinatal Quality Collaborative, or network of providers and stakeholders in facilities, to document challenges in provider training and the reimbursement process. Pilot testing may address variability in the reimbursement process, allowing for scale-up across states. However, developing a reimbursement process that includes networking between facilities, clinics, and health departments can be challenging for smaller hospital systems or facilities in rural areas (Palm et al., 2020), adding complexity to statewide policy use.

Further complicating challenges of payment methodology implementation, in 2015, the upfront cost of a LARC device ranged from $598 to $703, depending on device type, and reimbursement of insertion procedures ranged from $71 to $135 (Trussell, Hassan, Lowin, Law, & Filonenko, 2015). In efforts to provide fuller access to immediate postpartum LARC, delivery facilities have developed alternate strategies to offset costs such as engaging in privately funded family planning residency programs to decrease costs for insertion procedures (Ryan Residency Program, 2021), or participating in the 340B Drug Pricing Program, a program intended to offset costs and increase availability of comprehensive services for eligible patients (Health Resources & Services Administration, 2020). Although our review did not include specific cost information, future studies may consider cost–benefit, cost comparison, or cost effectiveness analyses to calculate more accurate expenditures and savings for provision of immediate postpartum LARC.

Observed policy differences indicate that payment methodologies more often include the cost of the device than provider reimbursement and may represent a reimbursement systems barrier. Providers are essential to LARC access. States that authorize them to bill and receive reimbursement for services such as insertion fees could allow for consistent implementation of policies across facilities and see decreases in observed disparities in accessing postpartum LARC. Provider champions can support implementation of reimbursement policies by providing the knowledge and experience to apply evidence in practice, using evidence to inform and promote reimbursement policy language, and engaging multidisciplinary stakeholders in discussion (Hill et al., 2019; Rodriguez et al., 2014; Hofler et al., 2017). Moreover, champions can communicate opportunities for systems changes at both the state and facility level leading to implementation of reimbursement policies (Okoroh et al., 2018). Champions promote provider awareness of the reimbursement process, timeliness, processing efficiencies, and can offer suggestions on sustainable reimbursement rate development accounting for billing structure (Hofler et al., 2017). Okoroh et al. (2018) describe a provider champion who functioned at the facility and state levels both as a clinical provider and state Medicaid medical director; this individual promoted statewide quality improvement efforts by leading a pilot at one facility to develop a tested, successful reimbursement process. Provider champions can both diffuse evidence-based guidance on best clinical practices to other providers (Curtis, Jatlaoui, et al., 2016; Curtis, Tepper, et al., 2016; Gavin et al., 2014) and promote the evidence at the facility leadership level to institute practice change such as provider billing for insertion procedures. Having a provider champion can be key to a successful reimbursement plan and scale-up to statewide policy (Kroelinger et al., 2019).

Because many insurance plans must now cover contraception without cost sharing, patient costs for LARC have decreased, and this cost reduction has been associated with increased use; enrollees in employer-sponsored health plans have been most affected by this change (Dalton et al., 2018; Heisel et al., 2018). However, Moniz et al. (2019) suggest that cost-sharing continues to exist for immediate postpartum LARC among some commercially insured women, impacting access to services. Ensuring all women can access the method of their choice is paramount to meet preventive health services recommendations (Gavin et al., 2014), improve reproductive autonomy through patient-centered counseling to reduce potential coercion (Mann, White, Rogers, & Gomez, 2019; Sznajder, Carvajal, & Sufrin, 2020), and address biases associated with more frequent offering of LARC to women with public insurance (Dehlendorf et al., 2010) rather than private insurance. Of note, all publicly available state policies identified Medicaid directly; we could not identify other publicly available non-Medicaid or private plans as payors for reimbursable services. This factor limits understanding of immediate postpartum LARC reimbursement among a significant proportion of health systems, payors, and provider services in care delivery. Immediate postpartum LARC policies can be provided within a patient-centered framework that prioritizes individual patient preferences for method choice and counseling (Dehlendorf, Fox, Sobel, & Borrero, 2016) while also addressing the continued burden of cost for patients, as consumer needs drive implementation of services (Batra & Bird, 2015). Further research on how policy implementation impacts patient experiences for both the publicly and privately insured is warranted.

There are several limitations to this study. Although publicly available policies exist for many states, most statewide policies are specific to state Medicaid programs. Very few publicly available policies for private insurers are accessible for review, limiting the generalizability of our findings to Medicaid policies. Second, by limiting our review to publicly available policies, we may have missed nonpublic or unpublished policies. Third, because of the data collection time frame, some state policies may have been developed, amended, or repealed, potentially affecting our analysis. Fourth, we did not include policy review for the District of Columbia or any U.S. territories or freely associated states. Finally, our review did not include extraction of information on the adequacy of reimbursement or specific billing codes, limiting the study of policy differences necessary for a more detailed understanding of how billing and reimbursement operate within facilities. Authorizing language typically included grouped entities such as delivery facility or provider rather than specific hospital systems, provider groups, or companies, and therefore we could not analyze language beyond these broad categories to understand facility-specific barriers to LARC availability. Billing codes included in policy documents range from a list of DRG, healthcare common procedure coding system, current procedural terminology, or J codes but were inconsistently reported, and, therefore, excluded from the data classification scheme. Our findings on the variability in reimbursement methods provide a snapshot of state strategies across the US, from 2017 to 2018, regardless of these limitations.

Despite challenges of reimbursement and variable payment methodologies, states are implementing multiple strategies to address barriers in policy implementation (Kroelinger et al., 2019). To further support state efforts, from 2014 to 2018, the Association of State and Territorial Health Officials (2020) in partnership with the Centers for Disease Control and Prevention, the CMS, and the Office of Population Affairs convened a Learning Community to provide technical assistance to 26 states and one territory seeking to increase access to the full range of contraceptive options, and in particular, immediate postpartum LARC (Association of State and Territorial Health Officials, 2020; DeSisto et al., 2017; DeSisto et al., 2019; Kroelinger et al., 2019; Kroelinger et al., 2015; Rankin et al., 2016). The Learning Community activity has provided resources to support states in the immediate postpartum LARC implementation process (Kroelinger et al., 2019; DeSisto et al., 2019), including return on investment tools, revised modifier codes for billing, and broader payment strategies for billing and reimbursement to support implementation of state policies (Association of State and Territorial Health Officials, 2020). Additionally, state public health agencies, in partnership with Medicaid programs and individual facilities or hospital systems, are providing guidance to enhance or supplement the global obstetric fee for effective billing of device costs and insertion fees (Brown et al., 2020; Lacy, McMurtry, Scott, Barker, & Zite, 2020; Rodriguez et al., 2014; Steenland, Pace, Sinaiko, & Cohen, 2019), with payment reform pilots at individual facilities supported by state Perinatal Quality Collaboratives and Managed Care Organizations (Hofler et al., 2017; Lacy et al., 2020; Steenland et al., 2019). For example, a recent policy change in one state to allow billing for immediate postpartum LARC separate from the global obstetric fee resulted in increases in receipt of LARC immediately postpartum among all women, and a significant decrease in short interval pregnancies among adolescents relative to what was expected without policy change (Steenland et al., 2019). States also reimburse outpatient LARC claims for inpatient insertions immediately after labor and delivery (Hill et al., 2019), offering alternative payment strategies for other states to consider during policy language revision or when existing policies offer less flexibility in billing for services.