CA
| CO | CT | DE | DC
| FL | GA | IN | IA
| KS |
KY
| ME | MD | MA | MI
| MN
MT
| NE | NV | NJ | NM
| NY | ND | OH | OK
| PA | SC | TX | UT
| VA | WA | WV | WI
"6.7.4.5
Family Planning: General Requirement
The Contractor
will provide the full array of family planning services covered under the
Contract without Prior Authorization. Medi-Cal Members have the right
to access family planning services through any family planning provider.
The Contractor will inform its Members in writing of their right to access
any qualified family planning provider without Prior Authorization as required
in Section 6.9.5(P), Membership Services Guide." California Contract,
page 121.
CO
"EXHIBIT A
COVERED SERVICES…
A.10
Family Planning Services
Clients may
receive services from the Contractor or from any Medicaid family planning
provider for family planning services. No referral is required. (Prenatal
care and gynecological services are not included.)" Colorado Contract,
Exhibit A, page 23.
CT
"3.14
Family Planning Access and Confidentiality
a. The
MCO shall notify and give each Member, including adolescents, the opportunity
to use his or her own primary care provider or utilize any family planning
service provider for family planning services without requiring referral
or authorization…" Connecticut Contract, page 24.
"Appendix L:
Bulletins, Memos and Policy Transmittals...
Family Planning/Abortion
Medicaid Policy...
Member consent
regarding family planning services… The PCP cannot act as a gatekeeper
to limit recipient referrals for family planning services. Unrestricted
access to family planning services, is a federal mandate for Medicaid recipients…"
Connecticut Contract, Appendix L, pages 2-3.
DE
"6.2.4 Family
Planning
Although family
planning services are included within the Basic Benefit Package, these
services can be directly accessed by Diamond State Health Plan, Medicaid
individuals without prior authorization through any Diamond State Health
Plan, Medicaid provider (who will bill the MCO and be paid on a fee-for-service
basis).
Access to family planning services without prior notification is a federal law. Under 1987 OBRA Section 4113 (c) (1) (B), ‘enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization, or a similar entity shall not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a) (4)(c). Therefore, Diamond State Health Plan, Medicaid members must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCOs provider network, without prior authorization. While family planning is a benefit of the Title XXI program, this ‘freedom of choice’ option does not apply to the Title XXI program.
All contracting MCOs are required to provide their Diamond State Health Plan, Medicaid members with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO's network of providers...
In addition, all contracting MCOs are required to provide timely reimbursement of out-of-network family planning and related STD services consistent with services covered in their contracts…" Delaware RFP, page II.31.
DC
"5. Family
Planning Services and Supplies
a.
Provider is responsible for coverage of family planning services and supplies
identified in Attachment I and for provision of such services if a request
for assistance in obtaining such services is made by the enrollee.
c.
Provider may not require enrollees to seek prior authorization for such
services." District of Columbia Contract, page 25.
FL
"7. Family
Planning Services...
e. Pursuant
to federal requirements, the plan shall allow each member to obtain family
planning services from any participating Medicaid provider and requires
no prior authorization for such services…" Florida Contact, pages
81-82.
GA
"SECTION 3
SCOPE OF SERVICES...
3.010
Offeror Responsibilities
The following
identify the responsibilities to be performed by the Offeror...
1. Evaluate
provision of unrestricted access to emergency services and family planning
services for recipients enrolled in GBHC…" Georgia RFP, page 7-8.
IN
"4.4.2.4
Self-Referral Services
Capitation
amounts include payment for the following services known as 'self-referral
services': ...
* Family planning services..
HCFA interprets family planning services to include birth control pills. Therefore, the enrollee must be allowed to obtain birth control pills on a self-referral basis. The OMPP recognizes the need for appropriate management of prescription medication in the interest of the enrollee’s health. However, the OMPP also recognizes the importance of removing barriers to family planning services. In order to reduce potential barriers to obtaining birth control pills, which may include, but may not be limited to transportation to pharmacies for periodic refills, MCOs must, at a minimum, reimburse for the dispensation of up to a 90-day supply of birth control pills, per enrollee, at one time, if prescribed." Indiana RFP, pages 4-7.
IA
"4.2.5.2.
Contracts with Title V and Title X providers...
The HMO shall
allow the Enrollee, including adolescent Enrollees, to use their own primary
physician and/or go to any family planning center for birth control, pregnancy
testing or reproductive health services without requiring a referral…"
Iowa Contract, page 24.
KS
"L. FAMILY
PLANNING SERVICE ACCESS AND CONFIDENTIALITY
Medicaid consumers
may receive covered services for Family Planning from any appropriate provider
without a referral… Recognizing that this service is not covered under
the capitation rate, give each member, the opportunity to use his or her
own primary physician for continuity of care or go to any family planning
provider for family planning services without requiring a referral…"
Kansas Contract, page 17.
KY
"The Member
Services staff shall be responsible for the following services and tasks:
...
•
Facilitating direct access…voluntary family planning..." Kentucky
RFA, page 53.
"7.9.3
Direct Access Services
The
Partnership shall ensure direct access and may not restrict the choice
of a qualified provider by a Member for the following services within The
Partnership's Network:
•
Voluntary family planning in accordance with federal and state laws and
judicial opinion..." Kentucky RFA, page 72.
ME
"5. Family
Planning. The Contractor shall:
a. provide
Enrollees with information to allow them to make informed choices regarding
the types of family planning services available, their right to access
these services in a timely and confidential manner and their freedom to
choose a provider within or outside of the HMO network..." Maine
Contract, page 23.
MD
"10.09.64.06...
.06 Access
and Capacity: Benefits and Appointments.
An MCO applicant
shall include in its application the following information or descriptions:
…
E. Documentation
of the applicant's preparedness to collaborate with providers of self-referral
services, and reimburse at the Department's established fee-for-service
rate, for permissible self-referred services, including: ...
(1) Family
planning services as specified in COMAR 10.09.65.20A(2), (6), and (7)…"
Maryland COMAR 10.09.64.06.
"10.09.65.20...
(2) An
MCO shall reimburse out-of-plan providers to whom enrollees have self-referred
for school-based services and family planning services specified in the
table below at the established Medicaid rates for the services or devices
indicated: …
(6) An
MCO may require enrollees to utilize in-plan providers for pharmacy and
laboratory services ordered by out-of-plan providers of self-referral services,
except as provided in §A(7) of this regulation.
(7) An
MCO shall reimburse out-of-plan providers at the Medicaid rate for medically
necessary and appropriate pharmacy and laboratory services when the pharmacy
or laboratory service is provided:
(a) In
connection with a self-referred service specified in §A(1) of this
regulation; and
(b) On-site
by the out-of-plan provider at the same location that the self-referred
service specified in §A(1) of this regulation was delivered to the
MCO's enrollee." Maryland COMAR 10.09.65.20.
"10.09.67.28...
.28 Benefits-Self-Referral
Services.
An MCO shall
be financially responsible for reimbursing, in accordance with COMAR 10.09.65.20,
an out-of-plan provider chosen by the enrollee for the following services:
A. Family
planning services specified in COMAR 10.09.65.20A(2), (6), and (7)…"
Maryland COMAR 10.09.67.28.
MA
"Section 2.4
Covered Services...
B. Services
for Specific Populations
The Contractor
shall: ...
5. Provide
family planning services as follows:
a. Ensure
that MassHealth Standard Enrollees are made aware that family planning
services… are available to the Enrollee through any MassHealth family planning
provider, and that MassHealth standard Enrollees do not need authorization
in order to receive such services…" Massachusetts Contract, pages
36-38.
"APPENDIX C:
MCO COVERED SERVICES
Exhibit 1:
MCO Covered Services for MassHealth Standard Enrollees...
Family Planning...
Under Federal
law, a MassHealth Standard enrollee may obtain family planning services
from any MassHealth Standard enrollee may obtain family planning services
from any MassHealth provider of family planning services without MCO authorization…"
Massachusetts Contract, Appendix C, pages 1-2.
MI
"II-I SPECIAL
COVERAGE PROVISIONS...
3. Family
Planning services...
The contractor
agrees:
*That Enrollees
will have full freedom of choice of family planning providers, both in-plan
and out-of-plan…" Michigan Contract, pages 22, 24.
MN
"Section 6.1.7.
Family Planning Services.
A. The
HEALTH PLAN must comply with the sterilization consent procedures required
by the federal government and must ensure free choice of Family Planning
Services.
B. The
HEALTH PLAN may not restrict the choice of an Enrollee as to where the
Enrollee receives the following services, pursuant to Minnesota Statutes,
Section 62Q.14:
1) voluntary
planning of the conception and bearing of children, provided that this
clause does not refer to abortion issues...
C. The
HEALTH PLAN may require family planning agencies and other providers to-refer
patients back to the HEALTH PLAN under the following circumstances for
other services, diagnosis, treatment and follow-up:
1) abnormal
pap smear/coloposcopy;
2) infertility
treatment;
3) non-Family
Planning Services;
4) genetic
testing; and
5) HIV treatment."
Minnesota Contract, pages 48-49, 52.
"Section 6.19. Direct Access to Obstetricians and Gynecologists. Pursuant to Minnesota Statutes, Section 62Q.52, the HEALTH PLAN shall provide Enrollees direct access without a referral or prior approval to the following obstetric and gynecologic services: annual preventive health examinations and any subsequent obstetric or gynecologic visits determined to be medically necessary by the examining obstetrician or gynecologist; maternity care; and evaluation and necessary treatment for acute gynecologic conditions or emergencies. Direct access shall apply to obstetric and gynecologic providers within the Enrollee's network or care system, including any providers with whom the HEALTH PLAN has established referral patterns." Minnesota Contract, pages 68-69.
MT
"FAMILY PLANNING SERVICES- for purposes of self referral, family planning services are defined as the following:…" Montana Contract, page 27.
"2.5.1 (B)
Family Planning Service Access and Confidentiality...
Per Social
Security Act 1905(a)(2)(c): Give each enrollee, including adolescents,
the opportunity to use his or her own PRIMARY CARE PROVIDER or go to any
family planning provider for family planning services without requiring
a referral…" Montana Contract, page 43.
NE
"4.1.22 The term 'Family Planning Services' means...Treatment for sexually transmitted diseases (STD) pursuant to this contract shall be reimbursed by the plans in the same manner as family planning services, without referral or authorizations by the Primary Care Physician(PCP)/plan…" Nebraska Contract, page 9.
"13.22 Provision of Services: The plan shall coordinate activities with the Department, other NHC contractors, and other providers for services outside the Basic Benefits Package, as appropriate, to meet the needs of the client, and ensure that systems are in place to promote well managed patient care, including, but not limited to...
(d) Unrestricted access to 'protected' services such as…family planning services…" Nebraska Contract, page 85.
"13.44.3 Unrestricted Services: The plan shall not require authorization for family planning services...The plan shall allow the client to access these services from any Medicaid-enrolled provider s/he chooses, and is not limited to providers within the plan’s network. The plan shall allow the client to access these services without a referral, even if the plan contracts with Medicaid to provide these services…" Nebraska Contract, page 93.
NV
"H. Out-of-Plan
Services…
1.
Family Planning A managed care participant has the right, by federal
regulation, to receive family planning services from any qualified provider,
even if the provider is not part of the Contractor's provider network.
The Contractor may not require the service to be prior authorized…"
Nevada Contract, page 25.
NJ
"ARTICLE 10
COVERED HEALTH
CARE SERVICES...
10.9
The contractor's enrollees may obtain family planning services from either
the contractor's family planning provider network or from any other qualified
Medicaid family planning provider…" New Jersey Contract, pages 51-52.
"1.95
'Referral Services' means those health care services provided by a health
professional other than the primary care physician and which are ordered
and approved by the primary care physician or the contractor.
Exception
A: an enrollee shall not be required to obtain a referral or be otherwise
restricted in the choice of family planning provider from whom the enrollee
may receive family planning services…" New Jersey Contract, page
20.
"ARTICLE 12
ENROLLEE NOTIFICATION
12.1
Prior to the effective date of enrollment, the contractor shall provide
each enrolled case or, where applicable, an authorized person, with a…member
handbook, the content and format of which shall have including...but not
limited to: ...
F. A notification of the enrollee's right to obtain family planning
services from the contractor or from any appropriate Medicaid participating
family planning provider (42 DFR 431.51(b))…" New Jersey Contract,
page 68.
NM
"2.A.1.e.ii
The CONTRACTOR shall provide each member with written information that
instructs members about how to obtain primary and specialty care, including:
(A)
a list of providers, by provider type and specialty, available through
the CONTRACTOR and how to access them; such list, at the option of CONTRACTOR,
may be limited to primary care providers and those providers to whom members
may self-refer, including, but not limited to, family planning providers..."
New Mexico Contract, page 5.
"2.C.14 Family
Planning Services and Providers:
The CONTRACTOR
shall give each member, including adolescents, the opportunity to use his
or her own primary care provider or go to any family planning center for
family planning services without requiring a referral. Clinics and
providers, including those funded by Title X of the Public Health Service
Act, shall be reimbursed by the CONTRACTOR for all family planning services
regardless of whether they are a participating or non- participation provider.
Unless otherwise negotiated, the CONTRACTOR shall reimburse providers of
family planning services at the Medicaid rate." New Mexico Contract,
page 32.
"2.C.14
Family Planning Services and Providers:
Federal law
prohibits restriction of access to family planning services for Medicaid
clients. The CONTRACTOR shall implement policies and procedures defining
how members are educated about their right to family planning services,
freedom of choice, and methods of accessing such services." New Mexico
Contract, page 32.
NY
"10. BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES…
10.4 Provision
of Services Through Participating and Non-Participating Providers
With the exception
of ... Family Planning Services described in Section 10.11 of this Agreement...the
Benefit Package must be provided and authorized by the Contractor through
Provider Agreements with Participating Providers, as specified in Section
22 of this Agreement….
10.11
Family Planning and Reproductive Health Services
a) Nothing
in this Agreement shall restrict the right of Enrollees to receive Family
Planning and Reproductive Health Services from any qualified Medicaid
provider, regardless of whether the provider is a participating provider
or a non-participating provider, without referral from the Enrollee's PCP
and without approval from the Contractor.
b) The Contractor agrees to permit Enrollees to exercise their right to obtain Family Planning and Reproductive Health Services as defined in Part C-1 of Appendix C, which is hereby made a part of this contract as if set forth fully herein, from either the Contractor, if family planning is a part of the Contractor's Benefit Package, or from any appropriate Medicaid enrolled Non-Participating Family Planning Provider without a referral from the Enrollee's PCP and without approval by the Contractor...
10.16
Services for Which Enrollees Can Self-Refer...
d) Family
Planning and Reproductive Health Services.
Enrollees may
self-refer to family planning and reproductive health services as described
in this Section and Appendix C of this Agreement…" New York Contract,
pages 10-1-10-9.
ND
"2.4.
Family Planning Service Access and Confidentiality
1) The
Contractor shall give each enrollee, including adolescents, the opportunity
to use any participating provider or go to any family planning center for
family planning services without requiring a referral...
(3) For
purposes of self-referral, family planning services are covered and are
defined as:
a) Reproductive
health exams;
b) Patient
counseling;
c) Patient
education;
d) Lad
tests to detect the presence of conditions affecting reproductive health,
such as those involving the thyroid, cholesterol/triglycerides, prolactin,
pregnancy tests, and diagnosis of infertility;
e) Sterilizations
as defined by Department as defined by Department rules;
f) Screening,
testing and treatment of and pre and post test counseling for sexually
transmitted diseases and HIV;
g) Family
planning medications and supplies provided by Title X clinics; and
h) The
diagnosis but not the treatment of infertility." North Dakota Contract,
Attachment C, page 10.
OH
"Family Planning Services… All managed care enrollees are permitted to self-refer to family planning services provided by qualified family planning providers (QFPPs)…" Ohio RFP, page 27.
"5101:3-26-03
Managed care plan: Covered services...
(I) Exclusions,
limitations and clarifications...
(3) MCPs
must advise enrollees via the member handbook of the ability to self refer
to family planning services provided by qualified family planning providers,
as specified by the MCP. MCPs are responsible for payment of claims
for such family planning services." Ohio RFP, Appendix E, OAC 5101:3-26-03,
pages 1-3.
OK
"2.5.4
Transportation Services...
2.5.4.3
Transportation for Adolescents Self-Referring for Family Planning Services
For adolescents
self-referring for family planning services out of network, the Authority
will continue to prior authorize and pay directly for transportation services.
The Authority will pay for these services on a fee-for-service basis…"
Oklahoma RFP, pages 27-29.
"2.8.7
Self-Referral for Designated Services
2.8.7.1
General
Except for
the categories described below, Health Plan may require members to obtain
authorization prior to receiving any non-emergent, non-primary care services
included in the pre-paid benefit package...
2.8.7.5
Family Planning Services
Health Plan
must allow adolescent (under age 18) members to obtain family planning
services from any qualified provider. Health Plan must allow adults
to obtain family planning services from any network family planning provider.
Authorization from the member's PCP shall not be required to access family
planning services…" Oklahoma RFP, pages 44-45.
PA
"G. DIFFERENTLY
ACCESSED SERVICES...
The referral
authorization process shall not apply to the delivery of family planning
services which may be self-referred. The right of members to choose
a provider for family planning services shall not be restricted.
Members may access these family planning services and the HMO must pay
for the services out of plan…" Pennsylvania RFP, pages 49-50.
SC
"FAMILY PLANNING
AND COMMUNICABLE DISEASE SERVICES...
B. Communicable
Disease...
However, eligible
recipients have the freedom to receive family planning, services from any
appropriate Medicaid providers without any restrictions…" South Carolina
Contract, Appendix C, Tab 1, pages 3-4.
"4.5 Right
of Conscience/Ethical Limitations
The
Contractor has chosen to exercise its Right of Conscience and shall not
be responsible for payment for Medicaid covered services set forth in Appendix
C, Tab 4…
The Contractor
understands that it remains responsible to inform members that
a) family planning
services are not provided by the HMO;
b) such services
may be obtained through any provider who accepts Medicaid and will be reimbursed
by Medicaid directly on a fee-for-service basis;
c) no
referral is needed for such services…" South Carolina Contract, page
44.
TX
"6.7 FAMILY
PLANNING - SPECIFIC REQUIREMENTS...
6.7.2
Freedom of Choice. HMO must ensure that Members have the right to
choose any Medicaid participation family planning provider, whether the
provider chosen by the Member is in or outside HMO provider network…"
Texas Contract, page 40.
UT
"B. Member
Orientation
1.
Initial Contact - General Orientation...
During
the initial contact the CONTRACTOR Representative must provide, at a minimum,
the following information to the Enrollees or potential Enrollees: ...
b.
availability and accessibility of all Covered Services, including the availability
of family planning services and that the Enrollee may obtain family planning
services from Medicaid providers other than providers affiliated with the
CONTRACTOR..." Utah Contract, Attachment B, pages 5-6.
"F. Clarification
of Payment Responsibilities...
2.
When Covered Services are not the CONTRACTOR's Responsibility
a.
The CONTRACTOR is not responsible for payment when family planning services
are obtained by an Enrollee from sources other than the CONTRACTOR...
3.
The DEPARTMENT's Responsibility...
The
DEPARTMENT will not be required to pay for any Covered Services under Attachment
C which the Enrollee received from any sources outside the CONTRACTOR except
for family planning services." Utah Contract, Attachment B, pages
24-25.
VA
"9. Family
Planning Services and Supplies...
In accordance
with 42 U.S.C. §1396(a)(23)(B) and 42 C.F.R. § 431.51(b)(2),
as amended, the Contractor may not restrict an enrollee's choice of provider
for family planning services or supplies. The Contractor must cover
all family planning services and supplies provided by network providers
and by out-of-network providers…" Virginia Contract, pages 44-45.
WA
"4.9 Self-Referral to Family Planning Clinics and Health Departments: Members may self-refer for certain services which are also covered services under the agreement…" Washington Contract, page 17.
WV
"3.9 Family
Planning Access and Confidentiality
The Managed
Care Plan shall give each enrollee, including adolescents, the opportunity
to use his/her own primary care provider or go to any family planning center
for family planning services without requiring a referral…" West
Virginia Contract, page 12.
"3.5
Family Planning
Although family
planning services are included within the MCP's list of covered benefits,
Medicaid enrollees are entitled to obtain family planning services without
prior authorization through any Medicaid provider (who will bill the MCP
and be paid on a fee-for-service basis). MCPs must provide their
Medicaid enrollees with sufficient information to allow them to make an
informed choice including: … their freedom to choose a qualified family
planning provider both within and outside the MCP's network of providers...
In addition, MCPs are required to provide timely reimbursement of out-of-network family planning and related STD services consistent with services covered in their contracts…" West Virginia RFA, pages 19-20.
WI
"C. PROVISION OF FAMILY PLANNING SERVICES AND CONFIDENTIALITY OF FAMILY PLANNING INFORMATION - Give minors the opportunity to have their own primary physician for the provision of family planning services. This physician does not replace the primary care provider chosen by or assigned to the enrollee. All such information and medical records relating to family planning shall be kept confidential." Wisconsin Contract, page 12.