Neighborhood Health Plan EFP Coverage Update

Coverage and Eligibility Criteria

Covered EFP Services and Eligibility

Covered when ALL of the following are met

EFP eligibility: Member is a RIte Care member above the Federal Poverty Level (FPL), was pregnant and is within 12 months postpartum or 12 months since pregnancy loss, and is at risk of losing Medicaid eligibility12 months

From Policy Statement

Service type: Requested service is included in the CMS‑approved EFP list and the services enumerated by this policy (examples include: one gynecological annual exam per rolling year with one‑month grace period including Pap; family planning visits; colposcopy and repeat Pap as follow‑up; sterilization; select laboratory and cytopathology testing; surgical treatment including anesthesia for major complications of family planning procedures; interpreter/sign language services; selected STI testing, pelvic exams, pregnancy testing; FDA‑approved contraception methods and contraceptive management, counseling; and state‑supplied vaccinations and administration)

From Medical Coverage section

Medical necessity: Service must be medically necessary as determined by applicable NCD/LCD, InterQual, EOHHS recommendations, and Neighborhood clinical policies and procedures

From Prerequisites and Medical Coverage

Listed Codes (no criteria provided)

Listed Codes: The CPT/HCPCS codes listed below (Table 5 and Table 6 and Table 2 excerpts) are presented as codes that may be covered for EFP Laboratory Testing Services and gynecologic/anesthesia/procedure services; no additional medical-necessity criteria are provided in these code tables within this document fragment

See Tables 5 and 6 code lists in source

EFP does not cover services beyond those specifically authorized by the CMS-approved EFP service list. Transportation is explicitly excluded from the EFP benefit package. In addition, non-formulary drugs will not be covered under the EFP benefit.

No additional explicit exclusions are stated in the sections that list covered procedure and laboratory codes (for example, Table 5 and Table 2). The code tables are presented as codes that may be covered for EFP Laboratory Testing Services and gynecologic procedures, but the tables themselves do not contain separate exclusion language.

This payment policy is informational only and is not a guarantee of reimbursement. Claim payments are subject to member eligibility, plan benefit coverage, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations. The policy may be implemented differently across claims systems and Neighborhood reserves the right to update the policy at any time; all services billed are subject to audit.

Services that fall outside the CMS-approved EFP list are not covered under the EFP benefit. For the purposes of EFP coverage determinations, such services should be considered outside the scope of the program and therefore implicitly not eligible for payment through the EFP benefit.

Within the code listing sections (e.g., Table 5 and Table 2) there are no explicit statements using the phrase 'not medically necessary.' The document provides code lists and descriptors that may be covered for EFP Laboratory Testing Services and gynecologic procedures but does not expressly label any items in those tables as 'not medically necessary.'

Codes, Tables and Frequency Rules

Covered CPT/HCPCS Codes — EFP Annual ExamsmixedCovered

99394	Periodic comprehensive preventive medicine reevaluation and management, adolescent (12-17)
99395	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management, established patient; 40-64 years
S0610	Annual gynecological examination, new patient
S0612	Annual gynecological examination, established patient

Covered CPT Codes — EFP Family Planning Visits and contraceptive proceduresCPTCovered

99202	Office/outpatient visit, new patient, expanded problem focused
99203	Office/outpatient visit, new patient, detailed
99204	Office/outpatient visit, new patient, comprehensive
99205	Office/outpatient visit, new patient, high complexity
99211	Office/outpatient visit, established patient, minimal
99212	Office/outpatient visit, established patient, problem focused
99213	Office/outpatient visit, established patient, expanded problem focused
99214	Office/outpatient visit, established patient, detailed
99215	Office/outpatient visit, established patient, comprehensive
11976	Removal, implantable contraceptive capsules

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Covered CPT/Anesthesia Codes — EFP SterilizationmixedCovered

00851	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection
58565	Hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58600	Ligation or transection of fallopian tube(s)
58611	Ligation or transection of fallopian tube(s) at time of cesarean/intra-abdominal surgery
58615	Occlusion of fallopian tube(s) by device
58670	Laparoscopy with fulguration of oviducts
58671	Laparoscopy with occlusion of oviducts by device

Covered Laboratory and Cytopathology Codes — EFP Labs and testingCPTCovered

81000	Urinalysis, non-automated, with microscopy
81002	Urinalysis, non-automated, without microscopy
81003	Urinalysis, automated, without microscopy
81005	Urinalysis; qualitative or semiquantitative, except immunoassays
81007	Urinalysis; bacteriuria screen
81015	Urinalysis; microscopic only
81020	Urinalysis; 2 or 3 glass test
81025	Urine pregnancy test, by visual color comparison methods
85013	Blood count; spun microhematocrit
85014	Blood count; hematocrit (Hct)

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Covered Laboratory Codes — Table 5 (regardless of diagnosis)CPTCovered

81001	Urinalysis, automated, with microscopy
88174	Cytopathology, preservative fluid; screening by automated system
88175	Cytopathology; screening by automated system and manual rescreening or review
88365	In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure

Covered Anesthesia and Procedure Codes — Table 6CPTCovered

00940	Anesthesia for vaginal procedures; NOS
00942	Anesthesia for vaginal procedures; colpotomy, vaginectomy, etc.
00944	Anesthesia for vaginal procedures; vaginal hysterectomy
00950	Anesthesia for vaginal procedures; culdoscopy
00952	Anesthesia for vaginal procedures; hysteroscopy/hysterosalpingography
11981	Insertion, non-biodegradable drug delivery implant
11982	Removal, non-biodegradable drug delivery implant
11983	Removal with reinsertion, non-biodegradable drug delivery implant
56405	Incision and drainage of vulva or perineal abscess

Table 5 — EFP Laboratory Testing Services codesCPTCovered

81001	Urinalysis, by dip stick or tablet reagent... automated, with microscopy.
88174	Cytopathology, cervical or vaginal... collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision.
88175	Cytopathology, cervical or vaginal... with screening by automated system and manual rescreening or review, under physician supervision.
88365	In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure

Table 6 — Anesthesia and select procedure codes (partial)CPTCovered

00940	Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified.
00942	Anesthesia for vaginal procedures...; colpotomy, vaginectomy, colporrhaphy, and open urethral procedures.
00944	Anesthesia for vaginal procedures...; vaginal hysterectomy.
00950	Anesthesia for vaginal procedures...; culdoscopy.
00952	Anesthesia for vaginal procedures...; hysteroscopy and/or hysterosalpingography.
11981	Insertion, non-biodegradable drug delivery implant.
11982	Removal, non-biodegradable drug delivery implant.
11983	Removal with reinsertion, non-biodegradable drug delivery implant.
56405	Incision and drainage of vulva or perineal abscess

Table 2 procedure CPT codesCPTCovered

58662	Laparoscopy; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface
58740	Lysis of adhesions (salpingolysis, ovariolysis)
58800	Drainage of ovarian cyst(s), vaginal approach
58805	Drainage of ovarian cyst(s), abdominal approach
58820	Drainage of ovarian abscess; vaginal approach
58822	Drainage of ovarian abscess; abdominal approach
58825	Transposition, ovary(s)
58900	Biopsy of ovary, unilateral or bilateral
58920	Wedge resection or bisection of ovary
58925	Ovarian cystectomy

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Table 7 - EFP Interpreter ServicesHCPCSCovered

T1013

Sign language or oral interpretive services, per 15 minutes

Table 8 - EFP Immunization and Vaccine AdministrationCPTCovered

90460	Immunization administration through 18 years of age; first or only component
90461	Immunization administration through 18 years of age; each additional component
90471	Immunization administration; 1 vaccine (injection)
90472	Immunization administration; each additional vaccine (injections)
90473	Immunization administration by intranasal or oral route; 1 vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine

GYN annual exam frequency — inv-20

Allowed frequencyOne gynecological annual exam per rolling year with a one-month grace period (effectively 11 months between exams)

Included with examIncludes a Pap test as part of the annual gynecological exam

Coverage limit referenceGYN Annual Exam limited to 1 per rolling year

Uterus weight threshold — inv-21

Provider Responsibilities and Billing Notes

Prior Authorization

Medical necessity and eligibility verification

Providers must verify member eligibility, coverage and any required authorizations prior to rendering services. All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, state EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. Contact Provider Services at 1-800-963-1001 for questions and refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for plan-specific requirements.

Medically necessary services only
Verify eligibility, coverage & authorization prior to service
Refer to Neighborhood Prior Authorization Reference and Clinical Medical Policies

Billing Rule

Formulary requirement

Policy Background

Extended Family Planning (EFP) provides a limited set of family planning and related services to eligible RIte Care members who were pregnant and are within 12 months postpartum or 12 months since pregnancy loss and who are at risk of losing Medicaid eligibility. Covered services include contraception (certain FDA‑approved methods), contraceptive management and counseling, one gynecologic annual exam, Pap and pelvic exams, selected laboratory and STI testing, sterilization procedures, treatment of major complications related to family planning procedures, interpreter services, and state-supplied vaccinations and administration where applicable.

Key Definitions

Extended Family Planning (EFP) — inv-35

DefinitionExtended Family Planning (EFP) is a Medicaid program benefit for RIte Care members above the Federal Poverty Level who were pregnant and are now within 12 months postpartum or 12 months since pregnancy loss and who are at risk of losing Medicaid eligibility.

Eligible populationRIte Care members above FPL, postpartum up to 12 months or within 12 months since pregnancy loss

Benefit scope (summary)Provides a limited set of family planning services (contraception, contraceptive management, counseling, selected exams, lab/STI testing, sterilization, interpreter services, and selected procedures)

EFP Laboratory Testing Services — inv-36

Referenced categoryEFP Laboratory Testing Services — Table 5 identifies laboratory and cytopathology codes that may be covered under this category.

Table 5 codes

Document History

2025-10-27annual_reviewLatest

Annual policy review completed; no content changes noted.

2024-09-17annual_review

Annual policy review completed.

2023-09-05annual_review

Annual policy review completed and removed deleted CPT 58293.

OpenPayer

Extended Family Planning (EFP) — Coverage and Reimbursement Requirements