Contraceptive use among Medicare enrollees — including among beneficiaries of childbearing age who are on Medicare due to a permanent disability — varies greatly depending on whether they’re enrolled in Medicare Advantage (MA) or traditional Medicare, researchers reported.

Use of contraceptives was higher among MA enrollees compared with those in traditional Medicare, with significant variation by Medicare type with regard to the specific method used, according to Jacqueline Ellison, PhD, MPH, assistant professor of health policy and management at the University of Pittsburgh School of Public Health, and colleagues.

Among the sample of more than 200,000 enrollees, and after adjustment for covariates, the study found a significantly higher predicted probability of contraceptive use with MA versus traditional Medicare (20.0% vs 13.6%, respectively). In addition, “among MA enrollees with a noncontraceptive clinical indication, the predicted probability of contraceptive use was nearly twice that of enrollees without such an indication,” the authors wrote in Health Affairs.

Asked to speculate on that latter difference, Ellison said that although the investigators couldn’t tell whether an enrollee received a particular contraceptive for pregnancy prevention or for another indication, “my guess is that MA plans offer additional benefits to disabled enrollees beyond what traditional Medicare offers.”

Pregnancy Prevention Coverage Not Mandated

“Medicare does not mandate coverage of contraception for pregnancy prevention,” the investigators noted. “As a consequence, Medicare enrollees may be paying out of pocket or not using their preferred contraceptive method.”

“As more young people experience COVID-19-related disability, and in a political environment that is increasingly hostile to reproductive healthcare, policy change on a national scale is needed,” the authors wrote. “Alongside explicit protections against interference in contraceptive decision-making, Medicare coverage of all contraceptive methods without cost-sharing is needed to support the reproductive autonomy of people with disabilities.”

Medicare is the primary source of health insurance coverage for 8 million people with disability-based eligibility, the investigators noted in their introduction. Of those, about 3.5 million are of reproductive age. “We don’t always think about Medicare as a program for people of reproductive age, but it is a major source of health insurance coverage for reproductive-age people who live with disabilities,” Ellison said during a phone interview at which a public relations person was present.

“I didn’t even learn that Medicare doesn’t require contraceptive coverage until a few years ago, shortly after the COVID outbreak,” she continued. “In the context of the pandemic, which we know overwhelmingly affected people with disabilities and has actually increased the number of young reproductive age people living with disabilities, it felt important to try to understand more about how Medicare works or how it doesn’t work for people who can get pregnant.”

Role of Financial Barriers

In addition, contraceptives are among the most common preventive health services used, with about 65% of reproductive-age women using them during 2017 to 2019, the authors wrote. “Although federal law requires Medicaid and commercial plans to cover the full range of FDA-approved contraceptive methods without cost-sharing, Medicare is not required to cover contraceptives for pregnancy prevention.” One 2021 study from the Oregon Health & Science University found that participants explicitly listed Medicare’s lack of contraceptive coverage as a barrier to obtaining contraceptives. However, the program does cover contraception when it is used for non-contraceptive reasons, such as menstrual regulation or treatment of acne, menorrhagia, or endometriosis.

To find out more on the issue, the researchers looked at overall contraceptive use in 2019 among all Medicare enrollees — including those in traditional Medicare as well as those in MA. For data on traditional Medicare enrollees, they used a 20% random sample of Medicare Parts A, B, and D claims. And because Medicare doesn’t capture specific outpatient claims for MA members, they used the Optum Clinformatics Data Mart database to look at inpatient, outpatient, and pharmacy claims for those enrolled in MA.

“Both data sources contain the prescriptions and services provided, dates of service, patients’ sociodemographic characteristics, and unique patient identifiers,” the investigators wrote.

For patients with disabilities, Medicare eligibility requires receiving Social Security Disability Insurance benefits, which are only given to people with physical or mental impairments lasting at least 1 year and constraining the ability to work. Enrollees with disabilities can choose either traditional Medicare or a MA plan; in 2019, MA covered 34% of the Medicare population. Compared with Medicare enrollees whose eligibility is based on their age, those in Medicare due to disability “have lower incomes, are more likely to be Hispanic or Black, and are more likely to report cost-related barriers to care,” the researchers said.

Study Specifics

The study sample included 203,824 Medicare enrollees with disabilities, of whom 162,041 had traditional Medicare and 41,783 had MA. The sample consisted of enrollees ages 20 to 50 who identified themselves as female and had at least 12 months of continuous enrollment in 2019. The authors excluded those who had undergone tubal sterilization or intrauterine device (IUD) placement during the years 2010 to 2018 that would span into 2019.

The study also looked at whether subjects had any documented noncontraceptive clinical indication for contraception in the study year, including endometriosis, pre- or postmenopausal bleeding, polycystic ovarian syndrome, pre-menstrual dysphoric disorder, premenstrual tension syndrome, menorrhagia, dysmenorrhea, amenorrhea, irregular menstruation, menstrual pain, ovulation bleeding, or menstrual cramps. Researchers also analyzed participants’ age group, census region, race and ethnicity, and whether they were dually eligible for both Medicare and Medicaid.

The unadjusted rate of contraceptive use among the entire sample was 14.7%, with use slightly higher among MA enrollees (16.3%) compared with traditional Medicare enrollees (14.3%). Oral contraceptives were the most commonly used method (8.7%), followed by injectable contraception (3.7%), counseling (1.4%), sterilization (1.2%), IUD (0.9%), patch or ring (0.5%), and contraceptive implant (0.2%). A total of 67 enrollees had a claim for emergency contraception.

The authors listed several limitations to their study, including that they were unable to capture contraceptive services provided under the Medicaid program to dual enrollees, that the analysis didn’t provide insight into contraceptive use variation by functional impairment, and that because the study only looked at females, it didn’t include use of vasectomy, which is considered an elective procedure and is therefore not covered under Medicare parts A and B. “Finally, some enrollees may have undergone hysterectomy for pregnancy prevention or initiated another long-acting method before enrolling in Medicare, neither of which was captured in our analysis,” they wrote.

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