Beyond the freedom to choose. Medicaid, managed care, and family planning

In this article we examine the federal freedom-of-choice statute, which was enacted in the mid-1980s to protect Medicaid beneficiaries' access to timely and confidential family planning services. We also examine how these provisions have been implemented in 15 jurisdictions and provide a case study of 5 family planning programs. We found that this attempt to "carve out" family planning services from managed care has led to numerous problems. First, there is virtually no federal guidance concerning to which services and supplies the exemption applies. Second, there are no guidelines as to how carve-outs are to function. Therefore, if managed care systems are inaccessible or nonresponsive to reasonable community care seeking patterns, then a carve-out carve-out may be the only answer. Carve-outs should be used as a last resort, however, because they are so difficult to design.