This December marks the one year anniversary of the U.S. Food and Drug Administration (FDA) announcement that it would finally put an end to some of the onerous restrictions on mifepristone, one of the two drugs typically used in a medication abortion. More specifically, the FDA announced that it would remove the in-person dispensing requirement and allow pharmacists to dispense mifepristone if they become certified. The permanent lifting of the in-person dispensing requirement was long overdue as numerous studies have shown telehealth medication abortion (TMAB) to be extremely safe and advocates have called for these changes to remove a major federal barrier to telehealth service delivery. This FDA action builds on the wave of changes to telehealth service delivery we’ve seen in the wake of the COVID-19 pandemic. As millions of Americans depended on telehealth to obtain care, states across the country acted swiftly to expand telehealth access by improving insurance coverage, including coverage mandates, payment parity requirements, and other changes to remove barriers to telehealth service delivery.
The new access opportunities created by telehealth service delivery are paramount now that the Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization has overturned Roe v. Wade and eliminated the constitutional right to abortion. While telehealth delivery of medication abortion cannot remedy the abortion access crisis, it holds the potential to reduce barriers and improve access to care, particularly for those in rural areas, people with low incomes, people with disabilities, and other populations that face systemic barriers to care.
In recognition of the one year anniversary of the changes to the FDA’s restrictions on mifepristone (and in anticipation of the FDA announcement of the final guidance for the pharmacist certification process), the National Health Law Program has issued a report analyzing the Medicaid telehealth medication abortion coverage policies in six key states: Alaska, Connecticut, Hawaii, Maine, Montana, and Oregon. In addition to the report, we have created fact sheets for the states we analyzed, outlining the major policies impacting TMAB and assessed the overall abortion access landscape in each state.
Overall, the results of our comprehensive survey of the TMAB coverage and reimbursement landscapes in the six target states revealed a lot of positive policy changes that improved Medicaid coverage of telehealth service delivery. For instance, states have established more robust coverage of the full spectrum of telehealth modalities, enhanced telehealth payment parity policies, and removed some restrictions around sites of care and patient-provider relationships. All of these policy changes are essential to removing unnecessary barriers to TMAB, ensure patients have the flexibility to choose their preferred modality for care, and make the provision of abortion care sustainable for providers. However, there still exists substantial room for improvement in ensuring equitable access to TMAB through comprehensive Medicaid coverage, but the dimensions of improvement varied between states.
In addition to analyzing the major trends in these six states, the report provides a series of recommendations for policy changes and clarifications states could pursue in order to further improve coverage and access to medication abortion for Medicaid enrollees. These recommendations include:
- Allowing providers to use telehealth to establish a relationship with new patients;
- Issuing comprehensive guidance on reimbursement for TMAB, including providing full reimbursement without requiring an ultrasound or in-person interaction unless medically indicated;
- Providing coverage for all telehealth modalities, especially audio-only and asynchronous care; and
- Allowing out-of-state providers to deliver care via telehealth and consider expedited credentialing systems to facilitate participation.
As states grapple with the fallout from the Dobbs decision, we hope to see continued improvement in TMAB coverage and would encourage states to update their Medicaid telehealth coverage policies to bring them in line with the most updated FDA guidelines. This will be particularly true once the FDA announces the final guidelines for the mifepristone REMS and the certification process for retail pharmacists seeking authorization to dispense mifepristone. CMS can and should play a vital role in encouraging states to take action to update and improve their telehealth coverage policies and payment methods to facilitate pharmacist dispensing of medication abortion as allowed by the new mifepristone REMS. While telehealth is no panacea, Medicaid enrollees seeking medication abortion can gain from the opportunities that telehealth has offered to millions of U.S. residents during the public health emergency and will continue to do so after the pandemic ends.
