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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Family Planning Services
Visit Coverage and Limits
Covered when provided by enrolled Family Planning providers and meeting visit limits:
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:
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:
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
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Provider Enrollment, Documentation, and Billing Actions
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.
Prior authorization not specified in excerpt
The policy excerpt does not specify any prior authorization requirements for family planning services under this chapter.
No step therapy policy described
No step therapy policy for family planning drugs or services is described in the provided excerpt.
Step therapy not specified
The document does not specify a step therapy requirement in this excerpt.
Obtain and retain required consent (written for face-to-face; verbal for phone)
Obtain informed consent and maintain consent records: for any face-to-face encounter written consent is required; for any telephonic encounter verbal consent is required. Maintain appropriate consent documentation and, for sterilizations, complete and distribute consent form copies as required.
- Face-to-face encounters require written consent.
- Telephone encounters require verbal consent.
- Sterilization consent must meet federal requirements (see sterilization rules) and completed form copies must be handled per regulation.
Follow the Alabama Medicaid Provider Manual (Appendix C) for visit elements and forms
Use the Alabama Medicaid Provider Manual (including Appendix C) provided to enrolled providers for detailed visit elements, form completion instructions, and local program procedures.
- Appendix C details elements of each family planning visit and instructions for completion of forms.
Submit three copies of sterilization consent (Form 193) with sterilization claims
Sterilization claims will be paid only when consent forms are completed in conformity with the regulation, including submission of three copies of form 193 with the claim; failure to submit the completed sterilization consent form will result in the claim being returned.
- Three copies of form 193 must be completed and included per the sterilization regulation.
- Claims not accompanied by the required consent forms may be returned and not paid.
Noncompliance with Provider Manual procedures may trigger recoupment
Failure to follow procedures outlined in the Alabama Medicaid Provider Manual may result in recoupment of claims paid to the provider.
Definitions and Reference Terms
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.
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