Addressing the STI Epidemic Through the Medicaid Program: A Roadmap for States and Managed Care Organizations

Chlamydia, gonorrhea, and syphilis are all detectable and treatable, yet rates of these 3 bacterial sexually transmitted infections (STIs) are soaring in the United States. ¹ If left untreated, both chlamydia and gonorrhea can lead to costly and burdensome complications, including pelvic inflammatory disease and infertility.^2,3 Untreated primary syphilis can lead to severe sequelae including death, and congenital syphilis can lead to miscarriage, stillbirth, prematurity, low birthweight, and death.^4,5 People who develop these complications because of untreated STIs have high medical costs throughout their lifetime.^6,7 Although rates of chlamydia, gonorrhea, and syphilis have been rising among all racial/ethnic groups, African American and Latinx people have persistently higher burdens of infection than White people. ⁸

STIs are also associated with an increased risk of acquisition and transmission of HIV. Their effect on the HIV epidemic is substantial: a 2019 study estimated that 1 in 10 HIV infections among men who have sex with men in the United States is attributable to chlamydia and gonorrhea infection. ⁹

In response to these challenges, the US Department of Health and Human Services released its first-ever STI Federal Action Plan in December 2020. ¹⁰ The Medicaid program could be a crucial partner in implementing that strategy. Medicaid covers 73 million people and is the dominant payer for family planning services and prenatal care for low-income women.^11,12 In addition, Medicaid eligibility overlaps with critical markers for STI risk; for example, a 2013 study found elevated STI risk among young adults at lower income levels compared with young adults at higher income levels. ¹³ The program is already playing an important role: Medicaid pays for a disproportionate share of STI-related visits compared with other payers, and people with Medicaid or other public health insurance are more likely to receive STI screening than people with private or no health insurance.^14,15

However, more work needs to be done. An enhanced focus on STIs through the Medicaid program could have a substantial effect on the STI epidemic. Medicaid’s role will be particularly important in light of policy shifts in the Title X federal family planning program, a major funder of STI and other reproductive health services. Recent regulatory changes in program scope and structure have led hundreds of health departments, nonprofit organizations, and community health centers to withdraw from the program rather than adapt their services to the new requirements.^16,17

A team of researchers from the George Washington University School of Public Health recently completed a research project for the Centers for Disease Control and Prevention (CDC), Division of STD Prevention, that identified ways to expand access to STI screening and treatment services through the Medicaid program. Focusing on 4 states with high STI rates, researchers at George Washington University spoke with Medicaid agency staff members, public health officials, STI service providers, and national experts in STIs and Medicaid. In addition, the team took a national perspective by reviewing a broad range of peer-reviewed and policy documents. Because more than two-thirds of Medicaid beneficiaries are enrolled in managed care, ¹⁸ which offers opportunities and challenges for influencing the delivery of services, the team reviewed model contracts between states and Medicaid managed care organizations (MCOs). ¹⁹

Drawing on that project’s findings, we offer a roadmap for state Medicaid agencies and Medicaid MCOs to initiate state-level actions to strengthen STI services. These step-by-step considerations are intended to guide collaborative efforts by public health agencies, Medicaid offices, and MCOs. A full report of the project’s findings is also available. ¹⁹

Identify Current Use of Services and Unaddressed Needs

The first step for states is to identify the baseline of services being used through Medicaid and the current and estimated future need for STI services.

Because the 3 bacterial STIs of greatest public health concern—chlamydia, gonorrhea, and syphilis—are reportable, state public health agencies have access to surveillance data for all reported cases, regardless of a person’s health insurance status. Based on trends in reported STI cases, states can estimate how the most affected populations overlap with Medicaid eligibility. For example, in a state with a full Medicaid expansion, low-income adults would generally be eligible for Medicaid, which includes comprehensive coverage for STI services. In addition, 25 states have more targeted Medicaid family planning expansions that cover a range of family planning and related services, including STI services, to people not otherwise eligible for Medicaid; 19 of those states cover STI screening for women and men. ²⁰ Public health officials can work with state Medicaid agencies to identify the estimated overlap of the populations in the state that are most affected by STIs with Medicaid eligibility and Medicaid family planning eligibility.

State Medicaid agencies and MCOs can also conduct claims analyses to characterize the use of STI services through the program. These claims analyses could identify all STI tests reimbursed by Medicaid, including tests that are negative and, therefore, not reported as part of surveillance. Data-sharing agreements, often already in place to permit analyses of HIV claims, can allow a crosswalk of claims data with surveillance data to identify trends in positive STI tests among Medicaid enrollees. Although states receive encounter data from MCOs, MCOs can also conduct their own internal claims analyses to guide their efforts for their own enrollees, ideally in collaboration with the state and other MCOs to coordinate efforts.

These analyses can help states and MCOs identify a range of priority areas. For example, claims and surveillance data often include demographic information, including data on sex, race, and ethnicity. Although data on race and ethnicity are often incomplete, and data on sexual orientation and gender identity are generally not captured, information collected from claims analyses could at least point toward priority populations of concern in the Medicaid population. In addition, claims data combined with surveillance data can help identify geographic areas that are particularly affected by STIs.

In addition to these data, Medicaid MCOs routinely report on certain Healthcare Effectiveness Data and Information Set (HEDIS) measures, ²¹ including one specific to STIs: the proportion of sexually active women aged 16-24 who are tested for chlamydia. ²² States also have the option of requiring MCOs to report non-HEDIS measures. Trends in plan performance on the chlamydia measure and others can help identify priorities moving forward.

Assess and Modify Policies and Procedures

The next step is for states to identify whether their Medicaid policies and procedures are adequately responsive to addressing STIs. The research project identified a set of key areas that states could consider.

Reimbursement of Multisite Testing

For some patients, CDC recommends that chlamydia and gonorrhea screening be based on samples taken from multiple sites. For example, for men who have sex with men, CDC recommends gonorrhea testing at sites of contact, including, if appropriate, the urethra, rectum, and pharynx. ²³ However, some payers, including Medicaid fee-for-service (FFS) programs and MCOs, reject multiple claims for the same pathogen in the same patient on the same day. In an informal survey of Medicaid medical directors on whether their state FFS programs would “pose any barriers to coverage of quarterly, multi-site STD testing,” 47% of respondents stated that their state program did not have any barriers, 7% said the state program would not pay for even a second laboratory test on the same day, and 47% were unsure. ²⁴

Inconsistent or inadequate payments are frustrating for health care providers (hereinafter, providers) and laboratories and could disincentivize comprehensive testing as recommended by CDC. States should assess their FFS reimbursement policies and systems, as well as the MCOs in the state, to determine if they pose any barriers to multisite testing. Solutions exist; for example, the National Correct Coding Initiative from the Centers for Medicare & Medicaid Services (CMS) includes modifiers that providers can use to note that samples beyond a certain threshold are in fact “distinct procedural services” that should be reimbursed, and state Medicaid programs can use a version of CMS’s system. Standard reimbursement across all MCOs in a state, as well as the state’s FFS system, would ensure timely reimbursement for providers and support evidence-based multisite testing when appropriate.

Self-Referral

Under federal law, Medicaid enrollees are allowed to see any Medicaid provider for family planning services, including STI screening, without a referral.^25,26 For MCO enrollees, self-referral is permitted even if the provider is not in network. However, the team’s research identified a lack of clarity concerning this policy at the state, provider, and patient level. For example, a review of MCO enrollee manuals in the 4 focus states identified substantial variation in how clearly the manuals explained self-referral overall and whether it applied to STI services. ¹⁹

Reimbursement for self-referred visits out of an MCO’s network may also be a challenge. To address this issue, states can pay out-of-network providers directly or can require MCOs to directly reimburse out-of-network providers for these visits. Providers interviewed for this project reported delays and challenges with reimbursement for these visits.

States could work with MCOs to determine whether their policies and systems are appropriately protecting enrollees’ right to self-refer for STI screening and other family planning services. States should also work with MCOs to identify the most effective way to reimburse out-of-network providers for family planning visits, including for STI care. If MCOs are responsible for reimbursing those providers, this obligation should be explained clearly so that providers are not burdened with unresponsive systems or a lack of clarity.

Nontraditional Reimbursement

STI services can be provided in settings and formats that are difficult to sustain on a typical reimbursement model. For example, walk-in appointments can increase access for young people and others at high risk of STIs but may be challenging to sustain without a predictable number of billable visits.

Medicaid MCOs should consider identifying clinics that provide a large volume of STI services to their enrollees and supporting providers through approaches (eg, grants or contracts) to bolster their capacity to provide services through flexible delivery models. In addition, states and MCOs could consider developing novel approaches to support health department disease intervention specialists. These specialists play a major role in STI prevention and control by locating and counseling people with STIs, but their reach is often limited by stagnant public health budgets.

Privacy

Patient concerns about privacy pose substantial barriers to the use of STI services, particularly among adolescents and young adults.^27-32 In some states, Medicaid programs or MCOs send explanations of benefits or denial notices to patients’ homes. In addition, a distinct challenge can arise for minors who have Medicaid and private health insurance: because Medicaid is the payer of last resort, providers generally must bill the private health insurance first, triggering notification to the parent who holds the policy. ³³

States and MCOs can review their policies to identify potential privacy problems for adolescents and others. Some states have implemented Medicaid-specific protections; for example, Illinois and New York State have policies for Medicaid MCOs that require the plans to suppress notices related to certain “sensitive services.”^34,35 Other states could consider similar policies.

Telehealth

Providers are developing a range of innovative approaches to offer sexual health services through telehealth, mitigating barriers such as transportation and stigma to encourage testing and other services. These services typically involve at-home sample collection, which is mailed to a laboratory for analysis; several platforms enable people who receive a positive test result to meet with a provider who can offer counseling and prescribe treatment. ³⁶ However, state Medicaid telehealth policies vary substantially in the kinds of services that are eligible, the site at which a patient must be located, and the type of provider that can be reimbursed. ³⁷

States could assess how their current Medicaid telehealth policies may support or hinder STI telehealth services, including whether they permit the patient to be located at home or have provisions to ensure the privacy of patients at an originating site. In addition, state Medicaid programs and MCOs should work with public health experts to identify accessible and sustainable methods for laboratory testing in conjunction with telehealth services.

Performance Measurement and Incentives

Most Medicaid performance reporting at the MCO or provider level is based on HEDIS measures. The previously described HEDIS chlamydia measure can be integrated into performance improvement efforts at the MCO or provider level. For example, South Carolina currently uses the chlamydia measure as 20% of a woman’s health index, a measurement tool that influences incentives awarded to plans that meet certain quality thresholds. ³⁸

States and MCOs should identify opportunities to improve STI screening and the delivery of other STI services through the HEDIS chlamydia measure and consider using other state-specific performance or outcome measures to monitor and incentivize plan and provider performance. States can also consider requiring MCOs to engage in collaborative Performance Improvement Projects ³⁹ (coordinated quality improvement initiatives for Medicaid MCOs) to target STI risk and service needs in the state.

Congenital Syphilis

In 2018, a total of 1306 cases of congenital syphilis occurred in the United States, a 39.7% increase from 2017 and a 183% increase from 2014. ¹ Prevention of congenital syphilis depends on timely syphilis testing among pregnant women, including repeated tests in the third trimester and at delivery for women at increased risk of syphilis, including women in communities with high rates of syphilis.^40-42 However, state requirements vary substantially: only 17 states require syphilis screening during the third trimester (5 of which require screening only if the woman is at high risk), and only 8 states require syphilis screening at delivery (5 of which require screening only if the woman is at high risk); 6 states have no congenital syphilis screening requirements.^43,44 Our research did not identify Medicaid barriers specific to prenatal syphilis testing; rather, several interviewees pointed to multiple challenges overall in ensuring that women receive timely and comprehensive prenatal care. ¹⁹

States and MCOs vary in how they reimburse providers and facilities for prenatal care. Public health agencies could work with their Medicaid agencies and Medicaid MCOs to identify how existing payment models and performance improvement initiatives related to maternal health and prenatal care might be modified to support appropriate and timely syphilis screening, including through better overall support of patient engagement in prenatal care.

Engage Providers and Patients

Addressing STIs through the Medicaid program will require meaningful, bidirectional engagement with providers and patients. Feedback from providers and patients can strengthen the development of any policy or programmatic shift that a state or MCO proposes. State public health agencies engaged in STI prevention or reproductive health more broadly may be helpful in convening appropriate stakeholders.

In turn, all of the policy changes or clarifications that states or MCOs implement must be clearly communicated to providers and enrollees. In addition to disseminating information about policy changes, state Medicaid programs and MCOs can share basic information about STIs, STI services, and the availability of services in the Medicaid program.

FFS programs and MCOs already reach providers and patients through a range of conduits. States and plans can share information with providers through letters, direct meetings, websites, and other outreach methods. It may also be useful to develop and distribute state-specific billing and coding resources for STIs and related family planning services.

For patients, states and plans can include information in enrollee manuals and ongoing digital and paper mailings. As one component of enrollee outreach, states could consider, by contract, requiring standardized language across MCO enrollee manuals to ensure that all members receive accurate and comprehensive information about STI services, including their right to self-refer.

Conclusion

Given the scale of the Medicaid program and its role in covering health and family planning services, state Medicaid programs and MCOs are integral to any such national response. Medicaid’s current prominent role in covering STI services, and the scale of the health and economic effects of untreated STIs, should help motivate states and MCOs to refine their approaches. The recommendations in this commentary and the accompanying report ¹⁹ should be considered in the context of changes in the way that people access care as a result of the COVID-19 pandemic. Through targeted use of data, careful assessment of existing programs and policies, and alignment of approaches that support STI services, states and MCOs can strengthen their response to STIs and improve health in their communities.