State changing vitamin rule in wake of birth-defects probe

Amid a growing cluster of birth defects in Central Washington, state officials are rewriting a Medicaid-coverage rule to give more women access to vitamins that can help prevent the deadly disorder.

The move follows a Seattle Times investigation into the state’s response to a yearslong spike in the birth defect. Among the findings: The state has mistakenly limited coverage for the crucial vitamins, even in the three counties affected by the deadly cluster, where up to 80 percent of births are paid for by the state.

Starting immediately, doctors who serve low-income women enrolled in the state’s Apple Health plan will be urged to recommend supplements containing folic acid to all women of childbearing age, not just those who are already pregnant.

“It needed to be clarified, and it is being clarified,” said Dr. Daniel Lessler, chief medical officer for the state Health Care Authority (HCA), which oversees Medicaid.

The agency intended for supplements to be covered outside of pregnancy, but that intent hasn’t been reflected in the Washington Administrative Code, perhaps deterring some doctors from prescribing the vitamins to more women, HCA officials said.

Covering the cost — which can be as low as 10 cents a day but is often higher — may encourage more poor women to take the supplements. That could help reduce the risk of fatal birth defects such as those affecting a growing number of pregnancies in Benton, Franklin and Yakima counties.

Since 2010, more than 40 mothers in the three-county area have lost babies to anencephaly, a defect in which the brain and skull fail to form properly in early pregnancy.

Folic acid, a B vitamin crucial to growth and development, has been shown to lower the risk of such neural-tube defects but must be ingested in the months before conception. It can be found in food, in enriched grains and in supplements.

Since 2005, the state code has limited coverage of prenatal vitamins, which contain folic acid, to women who are pregnant.

That’s contrary to the recommendation of medical experts, including the U.S. Preventive Services Task Force (USPSTF), which provides guidance for federal programs that pay for medical care.

The USPSTF recommends that all women “planning or capable of pregnancy” take a daily supplement of 400 micrograms to 800 micrograms of folic acid. Half of pregnancies are unintended, so health experts recommend the supplement for all women of childbearing age.

It’s not clear why the Washington limit has remained in place for so long, said Amy Blondin, an HCA spokeswoman. The state’s pharmacy processing system is programmed to allow coverage of prenatal vitamins without authorization for girls and women between the ages of 10 and 40, and for women older than 40 with authorization, she said.

HCA contracts with several managed-care health-insurance plans to administer Medicaid services, and those plans generally cover supplements for women of childbearing age. The rule primarily affects the 15 percent of women covered by fee-for-service Medicaid plans, Blondin said.

The gap troubled officials with the state chapter of the March of Dimes, which focuses on preventing birth defects and early births. In November 2014, the group sent a letter to the HCA, asking the agency to change the code, particularly as the birth-defects cluster in Central Washington continued to grow.

The March of Dimes wanted to “ensure access to folic acid as we were spreading the messages about its importance,” said Gina Legaz, state director.

But the request went unanswered for a year, until it was raised last month by The Seattle Times.

“If there’s something we can do, we should,” Dr. Charissa Fotinos, deputy chief medical officer, told a reporter at the time.

Within a week, HCA officials said they would amend the rule.

“After additional conversations with our chief medical officer and chief pharmacy officer, it appears that our written policies don’t align crisply with our intent,” Blondin wrote in an email.

Lessler said he couldn’t comment on why the agency didn’t act earlier. “What’s important for people to know is that it’s available to them now,” he said.

Starting last week, HCA officials began sending notices and fact sheets to Medicaid providers across Washington, alerting them that prenatal vitamins are covered for all women of childbearing age. The formal process to amend the Washington Administrative Code will begin soon, Blondin said.

The move could affect low-income women who struggle to pay for the supplements, which can cost up to $70 a month.

There are more than 1.3 million women of childbearing age in Washington state and at least 18 percent of them reported incomes below the federal poverty level, according to the most recent state figures.

In Yakima County, one of the counties affected by the birth-defects cluster, about 22 percent of women aged 15 to 44 live below the poverty level and about 80 percent of births are covered by Medicaid.

If HCA were able to negotiate a steep discount from retail prices, it might cost $230,000 a year to provide folic-acid supplements to protect those women, estimated Dr. Christopher Spitters, health officer for the Yakima Health District.

Washington is among 31 states that provide Medicaid coverage for supplements containing folic acid and 21 states that offer it at no cost to the patients, according to a review by the Kaiser Family Foundation.

But other states in that group, including Oregon, California and Minnesota, have policies that allow coverage for all women of childbearing age, not just those who are pregnant, a Seattle Times review shows. In Texas, officials expect that doctors prescribe prenatal vitamins only to pregnant women, but there’s no rule limiting coverage for others, a spokesman for the state’s Health and Human Services Commission said.

The change brings the state code into alignment with common practice, Blondin said.

But the trick can be asking for the right formulation of the prenatal supplements, said Dr. Portia Jones, who practices family medicine at Community Health of Central Washington, a federal health center.

“Medicaid covers 1-milligram tablets,” she said. “There are 400-microgram tablets, but they’re not covered.”

Providing coverage is crucial to ensure that low-income women can afford the vitamins.

“Depending on where they go, the differences in charges from pharmacies are very great,” Jones said. “It can range from $10 to $70 for the same thing.”

For Medicaid moms, that cost can be the difference between taking — or skipping — supplements that may prevent deadly birth defects, she added.

[This story was originally published by The Seattle Times.]

Photograph by Erika Schultz/The Seattle Times.