CurrentAlabama MedicaidPolicy N/A

Family Planning (Chapter 14) - Coverage Criteria

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Defines covered family planning services, eligible individuals, Plan First Waiver rules, sterilization consent requirements, covered procedures and supplies, and billing/reporting provisions for providers enrolled with Alabama Medicaid.

Policy Summary

PayerAlabama Medicaid

PolicyFamily Planning (Chapter 14) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 14, 2021

Last ReviewNov 18, 2020

Next Review DateN/A

Key ActionEnroll as a Plan First provider by completing a Plan First agreement to bill under the Plan First Waiver.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiplevisit types defined

8–55childbearing age range

141% FPLPlan First income limit

One lifetimeinitial visit limit

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CurrentAlabama MedicaidPolicy N/A

Family Planning (Chapter 14) - Coverage Criteria

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Know when Alabama Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerAlabama Medicaid

PolicyFamily Planning (Chapter 14) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 14, 2021

Last ReviewNov 18, 2020

Next Review DateN/A

Key ActionEnroll as a Plan First provider by completing a Plan First agreement to bill under the Plan First Waiver.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiplevisit types defined

8–55childbearing age range

141% FPLPlan First income limit

One lifetimeinitial visit limit

Coverage Criteria for Family Planning Services

Visit Coverage and Limits

Covered when provided by enrolled Family Planning providers and meeting visit limits:

Visit types and limits: Initial Visit: an in-depth evaluation of a new patient requiring establishment of medical records, comprehensive history, complete physical exam, appropriate diagnostic lab tests and/or procedures, contraceptive and STD counseling, and issuance of supplies or prescriptions as indicated. An initial visit is limited to one per provider per individual, per lifetime.; Annual Visit: re-evaluation of an established patient including interim history, complete physical exam, appropriate diagnostic labs/procedures, family planning counseling, and adjustment of contraceptive management as indicated. Limited to one per calendar year.; Periodic Revisit: follow-up evaluation including review of history, review of contraceptive effectiveness, counseling and adjustment/issuance of supplies as indicated. Limited to no more than four (4) revisits per calendar year.; Home Visit: brief evaluation in the home for established patients including abbreviated history, weight, blood pressure, counseling, and issuance of supplies if indicated. Limited to one visit during the 60-day postpartum period.; Extended Family Planning Counseling Visit: separate counseling service during the postpartum visit requiring a minimum of 10 minutes face-to-face contact. Limited to one service during the postpartum examination and not available to individuals who have undergone sterilization.; Routine laboratory screening (pregnancy test, STD/HIV test, Pap smear, hemoglobin/hematocrit, urinalysis) are covered when performed as part of the initial or annual family planning service.visit counts per year/lifetime

See Appendix C of the Alabama Medicaid Provider Manual for detailed criteria and required documentation.

Contraceptive Procedures

Covered when performed for contraceptive purposes and by or under supervision of a physician:

Procedures: Insertion or removal of implantable contraceptive capsules when performed by or under the supervision of a physician.; Insertion or removal of intrauterine devices when performed by or under the supervision of a physician.; Fitting of a diaphragm when performed by or under the supervision of a physician.physician performance/supervision

Medically approved pharmaceutical supplies and devices (oral contraceptives, foams, jellies, creams, diaphragms, IUDs, injections, implants) are also covered if provided for family planning purposes.

Plan First Waiver Eligibility

Plan First Waiver extends family planning eligibility to specific populations meeting ALL of the following where applicable:

Plan First basic eligibility: Applicant must have no creditable health insurance as defined by HIPAA and not be currently sterilized.; Applicant must meet age requirements (females 19 through 55; males 21 or older for vasectomy eligibility).; Applicant must furnish a Social Security number or proof of application for one.; Applicant must meet citizenship and alienage requirements.; Applicant must have family income at or below 141% of the Federal Poverty Level (a standard 5% FPL income disregard is applied if ineligible due to excess income).; Applicant must cooperate in establishing third-party medical benefits and apply for benefits to which they may be entitled.; Eligibility is subject to program-specific provisions (women with SOBRA-eligible children and SOBRA pregnant women have specified automatic or simplified application pathways; males are eligible for 12 months once determined eligible).age and income limits

Providers wishing to bill under the Plan First Waiver must enroll as Plan First providers by completing a Plan First agreement so the Plan First specialty code can be added to the provider record; certain tubal/vasectomy-only providers are exempt from enrolling.

The following are not covered as family planning services under Alabama Medicaid: abortions and sterilization by hysterectomy. Additionally, hospital charges incurred when a recipient decides not to be sterilized after admission for a sterilization procedure cannot be reimbursed as a family planning service. Any procedure or service provided to a woman who is known to be pregnant is not considered a family planning service.

Certain procedures and removals are explicitly excluded from family planning coverage and may instead be billed under other medical programs when medically necessary. Examples include removal of an intrauterine device (IUD) because the recipient has a uterine or pelvic infection, and removal of contraceptive implants due to medical complications. Colposcopy and biopsy of the cervix or vagina performed to diagnose or treat medical conditions are also not classified as family planning services. Diagnostic or screening mammograms and medical complications requiring treatment (e.g., perforated bowel) resulting from a family planning procedure are likewise excluded from family planning coverage and should be billed through the appropriate medical benefit if applicable.

Alabama Medicaid recipients are exempt from co-payment requirements for family planning services. Providers should refer to general billing guidance in Chapter 1 for additional billing rules when rendering family planning care.

Sterilization performed on a mentally incompetent or institutionalized individual is not payable by Alabama Medicaid. Sterilizations are subject to federal consent regulations: the individual must be at least 21 years old at the time consent is obtained, must not be mentally incompetent, must voluntarily give informed consent in accordance with regulatory requirements, and timing requirements for consent (generally at least 30 days but not more than 180 days before the procedure, with limited exceptions) must be met.

Coding and Eligibility Metrics

Covered services and suppliesmixed

No codes listed

Plan First income eligibility — key thresholds

Income eligibility limitIncome at or below 141% of the Federal Poverty Level (FPL)

Standard income disregardA standard income disregard of 5% of the FPL is applied if the individual is not eligible due to excess income

ApplicabilityApplies to Plan First Waiver applicants who would not otherwise qualify for Medicaid

Provider Enrollment, Documentation, and Billing Actions

Prior Authorization

Enroll as a Plan First provider and submit agreement

Providers who bill under the Plan First Waiver must enroll as Plan First providers by completing and submitting a Plan First agreement so the Plan First provider specialty code can be added to their provider record; providers who only perform tubal ligations and vasectomies (surgeons, anesthesiologists, and outpatient surgical centers) are exempt from enrolling.

Note

Prior authorization not specified in excerpt

The policy excerpt does not specify any prior authorization requirements for family planning services under this chapter.

Step Therapy

No step therapy policy described

Definitions and Reference Terms

Family planning services — covered items

Scope of servicesServices provided to prevent or delay pregnancy, including counseling, evaluation, contraceptive supplies and prescriptions, and specified procedures

Included visit typesInitial, Annual, Periodic revisit, Home, and Extended family planning counseling visits as described in Appendix C

Specific contraceptive proceduresInsertion or removal of implantable contraceptive capsules and intrauterine devices; fitting of a diaphragm; medically approved supplies and devices

Childbearing age (eligibility definition)

Age range (childbearing age)Defined for eligibility as between 8 and 55 years of age

Applies toFemales of childbearing age; males of any age may be eligible for family planning services as specified elsewhere

Background and Scope

Family planning services are those provided to prevent or delay pregnancy and include counseling, evaluation, contraceptive supplies and prescriptions, and specified procedures when provided by enrolled Alabama Medicaid family planning providers. Covered services encompass a range of visit types (for example, initial, annual, periodic revisits, home visits, and extended counseling), contraceptive methods and related supplies, and routine laboratory screening when performed as part of the initial or annual family planning service. Providers should follow the Alabama Medicaid Provider Manual (Appendix C) for detailed visit elements and documentation requirements.