Nonprofit recommends more patient info for Medicaid-funded abortion in Montana

DPHHS questions whether abortions paid through Medicaid fit ‘medically necessary’ definition

By: - September 15, 2022 3:09 pm

Photo illustration by PxHere (Creative Commons)

A nonprofit tasked with conducting an in-depth review of abortions in Montana that were covered by state Medicaid funds was unable to determine if the 221 cases met the definition of “medically necessary,” citing “lack of documentation.”

Mountain-Pacific Quality Health, a Helena-based nonprofit focused on improving health care networks, was tasked by the Montana Department of Public Health and Human Services to look at abortion cases that were covered by Medicaid from fiscal years 2019 to 2021.

The Hyde Amendment, enacted by Congress shortly after the recently overturned U.S. Supreme Court decision Roe v. Wade, prohibited Medicaid from paying for abortion outside exceptions for rape, incest or if the pregnancy endangered the patient’s life.

Following the state’s 1995 Jeanette R. v. Ellery decision, Montana pays Medicaid funds for abortions that meet the standard of being “medically necessary,” outside of the parameters set up in the Hyde Amendment.

In a DPHHS Interim Budget hearing Wednesday, Department Director Charlie Brereton said that physicians, pursuant to current Montana policy, are not required to submit additional clinical documentation to support that the abortion was medically necessary, but the patient’s life was not in danger, saying the extra paperwork is optional.

The mandatory form physicians have to fill out, the MA-37, requires one of three boxes be checked related to whether the pregnancy was due to rape or incest, health of the patient, or deemed medically necessary, along with the medical provider’s signature.

Brereton said that 25 of the total 221 cases had the optional additional clinical information from the health provider, and that all 25 came from one provider. The nonprofit MPQH looked at all cases involving rape, incest, or endangerment of the patient’s life, and said the additional information was not included on the other submitted forms, according to a review summary.

Bereton said that due to lack of documentation, Mountain-Pacific Quality Health was unable to determine if the 221 cases met the definition of “medically necessary” in ARM 37-82-102-18.

“Medically necessary service” means a service or item reimbursable under the Montana Medicaid program, as provided in these rules:
(a) Which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions in a patient which:
(i) endanger life;
(ii) cause suffering or pain;
(iii) result in illness or infirmity;
(iv) threaten to cause or aggravate a handicap; or
(v) cause physical deformity or malfunction.
(b) A service or item is not medically necessary if there is another service or item for the recipient that is equally safe and effective and substantially less costly including, when appropriate, no treatment at all.
(c) Experimental services or services which are generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of the Montana Medicaid program.
(i) Experimental services are procedures and items, including prescribed drugs, considered experimental or investigational by the U.S. Department of Health and Human Services, including the Medicare program, or the department’s designated review organization or procedures and items approved by the U.S. Department of Health and Human Services for use only in controlled studies to determine the effectiveness of such services.

MPQH also found there was insufficient documentation to indicate a life threatening situation existed or that the pregnancy was the result of rape or incest, according to Brereton, who said this was especially important in terms of receiving federal dollars or a federal match.

MPQH recommended as a result of the in-depth review that abortions covered by Medicaid require additional information on the MA-37 form, including “a brief history and physical exam with evidence of medical diagnosis and/or condition necessitating abortion, an estimate gestational age, and corroborating laboratory and imaging studies that support the medical diagnosis or patient condition.”

These recommendations would also update what is currently outlined in the physician related services manual.

This in-depth review came at the request of the Health and Human Services Interim Budget Committee and the Children and Families Interim Committee after DPHHS presented its report on Medicaid-covered abortion last September, as requested in House Bill 2, the big budget bill.

“I as director have grave concerns with these findings. We are evaluating various policy options. Nothing has been determined at this point in time but want you to know that we intend to take action in this regard and within our authority,” Brereton said Wednesday.

Interim Committee Chair Matt Regier, a Kalispell Republican, responded that it was “long overdue.”

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Nicole Girten
Nicole Girten

Nicole Girten is a reporter for the Daily Montanan. She previously worked at the Great Falls Tribune as a government watchdog reporter. She holds a degree from Florida State University and a Master of Science from the Medill School of Journalism at Northwestern University.