BOISE, Idaho (AP) - Idaho officials have submitted a Medicaid expansion waiver requiring patients to get referrals from primary physicians before they can get family planning services such as birth control, abortions or pregnancy care.

The Idaho Department of Health & Welfare last Friday submitted the waiver to the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services.

Waivers are required when states wants to deviate from Medicaid rules.

Idaho voters authorized Medicaid expansion in November with an initiative that passed with 61% of the vote after years of inaction by the Idaho Legislature. But lawmakers earlier this year added restrictions requiring five waivers, including the family planning waiver.

Republican Sen. Mary Souza of Coeur d’Alene proposed the family planning amendment to the bill, arguing that requiring referrals would increase the quality of care and save the state money.

She did not immediately return a phone message seeking comment on Tuesday.

Mistie Tolman, Idaho State Director at Planned Parenthood Votes Northwest and Hawaii, said the requirement would affect mainly women and was a “thinly masked attempt to cut off access to family planning providers such as Planned Parenthood.”

She said that because of the sensitive nature of reproductive health care, some women might feel less comfortable seeking referrals from family providers.

According to the nonpartisan Kaiser Family Foundation, about two-thirds of adult women on Medicaid are in their reproductive years, defined by the foundation as ages 19 to 49. The foundation says 44% of Medicaid recipients are children under age 18.

The expansion provides Medicaid to people earning up to a maximum of 138% of the federal poverty level. That maximum is about $17,000 a year for one person and $35,500 for a family of four.

Of Idaho’s estimated 1.8 million residents, about 286,000 as of Sept. 1 were covered by Medicaid, according to the Idaho Department of Health and Welfare. Medicaid expansion would add an estimated 90,000 people costing $400 million, with the federal government paying 90%.

Besides the family planning waiver, there are four other waivers in various stages of the process.

Idaho submitted a work requirement waiver late last month requiring recipients age 19 to 59 to work 20 hours a week to remain eligible for Medicaid. There are exemptions for medical conditions.

Federal officials in August rejected a “choice” waiver request as incomplete that would allow Idaho residents who qualify for the expansion to choose to stay on the state’s health insurance exchange.

Idaho Department of Health and Welfare spokeswoman Niki Forbing-Orr said Tuesday that the state is working with federal officials to supply the necessary information.

“They’re still negotiating,” she said.

A similar choice waiver is on hold because federal officials have told the state it may not be necessary.

A final wavier is expected to be released for public comment in November. It would allow Medicaid recipients to receive inpatient treatment for mental health and substance abuse disorders at a freestanding psychiatric hospital. Currently, those services are only available in the psychiatric unit of a full-service hospital.

Medicaid expansion enrollment begins Nov. 1, and coverage starts Jan. 1. The waivers could take months to process, with final decisions occurring after coverage starts and changing who is covered.

“We’ll cross that bridge when we get to it,” Forbing-Orr said. “If none of the waivers are approved on Jan. 1, Medicaid expansion is still going to happen.”

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