Download Family Planning - Health Choice Integrated Care

CHAPTER 4 – COVERED SERVICES
4.2 – FAMILY PLANNING
PROVIDER RESPONSIBILITIES FOR FAMILY PLANNING SERVICES
All providers are responsible for:
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Making appropriate referrals to health professionals who provide family planning services.
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Keeping complete medical records regarding referrals.
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Verifying and documenting a member’s willingness to receive family planning services.
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Providing medically necessary management of members with family planning complications.
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Notifying members of available contraceptive services and making these services available to all
members of reproductive age using the following guidelines:
o Information for members between 18 and 55 years of age must be provided directly to the
member or legal guardian.
o Whenever possible, contraceptive services should be offered in a broad-spectrum counseling
context, which includes discussion of mental health and sexually transmitted diseases,
including HIV/AIDS.
o Members of any age whose sexual behavior exposes them to possible conception or STDs
should have access to the most effective methods of contraception.
o Every effort should be made to include male or female partners in such services.
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Providing counseling and education to members of both genders that is age appropriate and
includes information on:
o Prevention of unplanned pregnancies.
o Counseling for unwanted pregnancies. Counseling should include the member’s short and
long -term goals.
o Spacing of births to promote better outcomes for future pregnancies.
o Preconception counseling to assist members in deciding on the advisability and timing of
pregnancy, to assess risks and to reinforce habits that promote a healthy pregnancy.
o Sexually transmitted diseases, to include methods of prevention, abstinence, and changes in
sexual behavior and lifestyle that promote the development of good health habits.
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Contraceptives should be recommended and prescribed for sexually active members. Providers
are required to discuss the availability of family planning services annually. If a member’s sexual
activity presents a risk or potential risk, the provider should initiate an in-depth discussion on the
variety of contraceptives available and their use and effectiveness in preventing sexually
transmitted diseases (including HIV/AIDS). Such discussions must be documented in the
member’s medical record.
COVERED AND NON-COVERED SERVICES
Full health care coverage and voluntary family planning services are covered.
Covered family planning services include:
 Natural Family Planning Education
 Medications:
 Birth Control Pills
 Depo Provera injections (J1055)
 Transdermal (Ortho Evra®)
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Last Revised: October, 2015
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Copper J7300 (Paraguard®)
Levonorgestrel-releasing J7302 (Mirena®)
Contraceptive intrauterine device S4989 (Progestacert®)
Vaginal Ring (Nuvaring®)
Emergency Contraception (Plan B®)
Supplies:
• Cervical Cap
• Condoms, foams, suppositories, creams and gels (male and female)
• Diaphragm
• OTC supplies require a script in order to be covered
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Surgical Procedures
Implanon® (subdermal implantable rod)
Tubal Ligation
Hysteroscopic tubal sterilization (such as the Essure Micro-Insert).
Male vasectomies
Other Covered Services:
 Medical and laboratory examinations for sterilization if criteria for sterilization are met. .
• Family planning counseling.
NON-COVERED FAMILY PLANNING SERVICES
• Pregnancy termination and/or pregnancy termination counseling
• Non-medically necessary hysterectomies
• Infertility
• Reversal of voluntary sterilization
STERILIZATION
The following criteria must be met for the sterilization of a member to occur:
• The member is at least 21 years of age at the time the consent is signed (see Consent for
Sterilization (Attachment D2a) (English);
• Mental competency is determined;
• Voluntary consent was obtained without coercion; and
• Thirty days, but not more than 180 days, have passed between the date of informed consent and
the date of sterilization, except in the case of a premature delivery or emergency abdominal
surgery. Members may consent to be sterilized at the time of a premature delivery or emergency
abdominal surgery, if at least 72 hours have passed since they gave informed consent for the
sterilization. In the case of premature delivery, the informed consent must have been given at
least 30 days before the expected date of delivery.
• For members under the age of 21, the provider must be able to demonstrate medical necessity
for the procedure with supporting documentation.
Any member requesting sterilization must sign Consent for Sterilization (Attachment D2a) (English)
with a witness present when the consent is obtained.
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Suitable arrangements must be made to ensure that the information in the consent form is effectively
communicated to members with limited English proficiency or reading skills and those with diverse
cultural and ethnic backgrounds, as well as members with visual and/or auditory limitations. Prior to
signing the consent form, a member must first have been offered factual information that includes all
of the following:
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Consent form requirements;
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Answers to questions asked regarding the specific procedure to be performed;
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Notification that withdrawal of consent can occur at any time prior to surgery without affecting
future care and/or loss of federally funded program benefits;
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A description of available alternative methods;
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A full description of the discomforts and risks that may accompany or follow the performing of
the procedure, including an explanation of the type and possible effects of any anesthetic used;
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A full description of the advantages or disadvantages that may be expected as a result of the
sterilization; and
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Notification that sterilization cannot be performed for at least 30 days post consent.
Sterilization consents may not be obtained when a member:
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Is in labor or childbirth
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Is seeking to obtain, or is obtaining, a pregnancy termination; or
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In under the influence of alcohol or other substances that affect the member’s state of
awareness.
PRIOR AUTHORIZATION REQUIREMENTS
Prior authorization is required for family planning services, sterilization or pregnancy termination.
Prior authorization must be obtained before the services are rendered or the services will not be
eligible for reimbursement.
To obtain authorization for family planning services, please contact Health Choice Integrated Care
Maternal Health and EPSDT Coordinator at 1-877-923-1400.
To obtain authorization for sterilization complete applicable form: Consent for Sterilization (Attachment
D2a) (English). Note: Permanent sterilization is only covered for Health Choice Integrated Care members
21 years of age or older.
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Last Revised: October, 2015