Other gynecological services

AZ | CA | CO | DE | DC | FL | HI | IL | IA | IABH | KS | MD | MN | MO | MT | NE
NV | NH | NM | NC | ND | OH | OK | OR | RI | TN | UT | VA | WA | WV | WI

“SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES…
Medically-Necessary Abortions: This service is covered for a member if the member suffers from a physical disorder, physical injury, or physical illness including a life endangering physical condition caused by or rising from the pregnancy itself, that would, as certified by a physician, place the member in danger of death unless an abortion is performed. The service is also covered for Title XIX and Title XXI members if the pregnancy is caused by rape or incest...” Arizona Contract, pages 10, 14.

“V. Family Planning Services...
Birth control services include information and instructions related to the following: ...
6. Vasectomy or tubal ligations...” Arizona Contract, page C5.

“F2. Sensitive Services means those services related to:
1. Family planning.
2. Sexually transmitted diseases (STDs).
3. Abortion.” California Contract, page 13.

“EXHIBIT A
COVERED SERVICES…
A.04 Medical Services
For specific procedures and indications of basic Medicaid coverage, the Medicaid Master Procedure File shall be considered the prevailing guide. The following is a general overview of such services.

PROCEDURE/SERVICE (REQUIRED COVERAGE)...
Abortion
Amniocentesis…

A.09 Inpatient/Outpatient Surgical Services: ...
Surgical procedures include: ...

PROCEDURE/SERVICE
(REQUIRED COVERAGE)…
Abortion

COMMENTS
Must be provided in the following situations, if requested:
a. In the presence of a medical condition that presents a serious and substantial threat to the life of the pregnant woman if the pregnancy comes to term or
b. When the pregnancy results from acts of rape or incest...

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.)…
PROCEDURE/SERVICE
(REQUIRED COVERAGE)...
Abortion...

A.17 Exclusions
The following services are excluded from coverage hereunder:
PROCEDURE/SERVICE
Abortions.

COMMENTS
Except when the life of the mother would be endangered if the fetus were carried to term, or if needed as the result of rape or incest

PROCEDURE/SERVICE
Amniocentesis.

COMMENTS
When provided solely for sex determination.” Colorado Contract, Exhibit A, pages 13-14, 21-24, 32.

“6.2.4 Family Planning...
6.2.4.1 Definition of Family Planning Services for Purposes of Out-of-Network Reimbursement This applies only to the
Diamond State Health Plan, Medicaid members

For the purpose of out-of-network reimbursement, family planning services are defined as those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy These services include:
(a) Health education and counseling necessary to make informed choices and understand contraceptive methods
(b) Limited history and physical examination
(c) Laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods*... (f) Follow-up care for complications associated with contraceptive methods issued by the family planning provider...
(j) Pregnancy testing and counseling

Pap smear is included as a family planning service if performed according to the United States Preventative Services Task Force Guidelines which specifies cervical cancer screening every one (1) to three (3) years based on the presence of risk factors (early onset of sexual intercourse, multiple sexual partners); however, Pap smear annual frequency may be reduced if three (3) or more annual smears are normal.
** Based on HCFA’s Medicaid policies, STD diagnosis and treatment and HIV testing and counseling, provided during a family planning encounter, are considered part of family planning services.

Abortions are not considered family planning for out-of-network reimbursement…” Delaware RFP, pages II.31-II.33.

“6.3.1 Federally Excluded Services...
Under federal law, Medicaid does not receive federal matching funds (called federal financial participation, or FFP) for certain services. Some of these excluded services are optional services which the State has elected not to cover. Therefore, MCOs will not be reimbursed to cover the following services:
(a) All non-medically necessary services
(b) Abortion unless by rape or incest, or if necessary to save the life of the mother
(c) Sterilization of a mentally incompetent or institutionalized individual. FFP for sterilization’s are only available if:

1. The individual is at least twenty-one (21) years old at the time consent is obtained, and 2. The individual is mentally competent, and 3. The individual has voluntarily given informed consent in accordance with all the requirements prescribed, and 4. At least thirty (30) calendar days, but not more than one hundred and eighty (180) calendar days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery…” Delaware RFP, page II.36.

“6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a))

The following services marked with an ‘X’ are covered by the State Child Health Insurance Program as part of a basic MCO benefit package when medically necessary with exceptions/limitations noted: ...

6.2.16. ‘X’ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16))…” Delaware RFP, Appendix A (SCHIP), pages A.18-A.19.

“H. COVERAGE AND BENEFITS
1. Covered services
a. This contract provide for coverage and provision by Provider of all medical assistance benefits and services that are listed in Attachment I, which is incorporated herein as part of this contract…” District of Columbia Contract, page 25.

“Attachment I
Covered Services

A. General Classes of Covered Benefits
Coverage of all benefits by Provide shall conform to the definition of the benefit set forth in federal statute and regulation. The following general categories of benefits are included in the state plan and are not otherwise exempt under this contract...

B. Family Planning Services and Supplies
The following family planning services and supplies shall be covered by Provider whether furnished by member of Provider’s network or by a Qualified Family Planning Provider:
1. Counseling and patient education.
2. Preventive examination and treatment in accordance with professionally accepted standards of clinical preventive practice.
3. All medically necessary laboratory tests including testing and counseling for HIV.
4. Medically approved methods, procedures, pharmaceuticals, supplies, and devices to prevent conception.
5. Treatment for sexually transmitted diseases including gonorrhea, herpes, syphilis, chlamydia and other diseases classified as sexually transmitted diseases by the CDC.” District of Columbia Contract, Attachment I, pages 1, 3.

“POLICIES AND PROCEDURES
HYSTERECTOMIES, STERILIZATIONS AND ABORTIONS
1. Hysterectomies - The plan must cover hysterectomies when they are non-elective and medically necessary. Non-elective, medically necessary hysterectomies must meet the following requirements to be a covered service: a. The recipient or her representative must have been informed verbally and in writing that the hysterectomy shall render her permanently incapable of reproduction. b. The patient or her representative, if any, has signed and been given a copy of the Acknowledgment of Receipt of Hysterectomy Information form...
The acknowledgment form is not required if the individual was already sterile before the hysterectomy or if the individual required a hysterectomy because of a life threatening emergency situation in which the physician determined that prior acknowledgment was not possible..

2. Sterilization - Non-therapeutic sterilization’s must be documented with a completed consent Form… Non-therapeutic sterilization is any procedure or operation that has the primary purpose of rendering an individual permanently incapable of reproducing and is neither: a. A necessary part of the treatment of an existing illness or injury; nor b. Medically indicated as an accompaniment of an operation of the female genitourinary tract.

The patient must be at least 21 years of age, mentally competent and not institutionalized in a correctional, penal, rehabilitative or mental facility...

The consent for sterilization cannot be obtained while the patient is in the hospital for labor, childbirth, abortion or under the influence of alcohol or other substances that affects the patient’s ...

3. Abortions - Abortions may be performed because the life or the month is or would be endangered if the fetus were carried to term and must be documented in the medical record by the attending physician stating why the abortion is necessary; or if the pregnancy is the result of an act of rape or incest. Abortions must be documented with a completed Abortion Certification Form...which shall satisfy federal and state regulations.” Florida Contract, pages 87-88.

“30.710 Medical Services...
* Sterilizations when federal requirements are met
* Hysterectomies when federal requirements are met...

The plan is responsible for meeting all federal requirements pertaining to Sterilizations and hysterectomies. Any financial penalties assessed DHS by the federal government for non-compliance shall be passed on to the plan…” Hawaii RFP, pages 16-19.

“For Adults:
The following are services for which payment will be made by health plans as separate medical services, as components of separate medical services, or as components of the ‘evaluation and management? services rendered by the health plan’ providers.
The services and periodicity are adapted from the 1996 U.S. Preventive Services Task force.

Screening: ...
5. Cervical Cancer Screening: …” Hawaii RFP, Appendix C, pages 1-2.

“Hysterectomies
A. For Adults
1. The medical procedure or operation to remove the uterus performed by a licensed physician is included only when medically necessary and when strict federal criteria are met...

B. For Children (EPSDT)
1. Services and requirements for adults apply.
2. In addition, the medical necessity criteria of hysterectomies for members under 21 should be restricted to life endangering medical conditions.” Hawaii RFP, Appendix F, pages 13-14.

“SERVICES AND MISCELLANEOUS ITEMS NOT COVERED BY THE HAWAII QUEST PROGRAM...
5. In vitro fertilization, reversal of sterilization, artificial insemination, sperm banking procedures…” Hawaii RFP, Appendix G, page 1.

“Sterilization
A. For adults
1. Any medical procedure, treatment, or operation performed by a licensed physician for the primary or sole purpose of rendering an individual permanently incapable or reproducing is included only when strict federal criteria are met...

B. For children (EPSDT)
1. Federal rules and regulations forbid payment for Sterilizations in all members under the age or 21…” Hawaii RFP, Appendix H, page 11.

“(b) Covered Services...
(3) Services to Prevent Illness and Promote Health
In addition, the Contractor shall exercise reasonable efforts to provide initial health screenings and a preventive care program to maximize the effectiveness of a prepaid health care system. The Contractor shall provide the following Covered Services to all Beneficiaries, as appropriate, to prevent illness and promote health: ...
* Family planning services and supplies...pregnancy testing, voluntary sterilization... related laboratory and diagnostic testing...
(6) Limited Covered Services

The following services and benefits shall be limited as Covered Services:
(A) Termination of pregnancy shall be provided only as allowed by applicable State and federal law (42 C.F.R. Part 441, Subpart E). In any such case, the requirements of such laws must be fully complied with and DPA Form 2390 must be completed and filed in the Beneficiary’s medical record.
(B) Sterilization services may be provided only as allowed by State and federal law (see 42 C.F.R. Part 441, Subpart F). In any such case, the requirements of such laws must be fully complied with and the DPA Form 2189 must be completed and filed in the Beneficiary’s medical record.
(C) If a hysterectomy is provided, the DPA Form 1977 must be completed and filed in the Beneficiary’s medical record...” Illinois HMO Contract, pages 19-22.

“(n) Required Minimum Standards of Care...
(2) Preventive Medicine Schedule (Services to Beneficiaries 21 and Over)...
d. Clinical Breast Examination...
i. Mammography...
m. Papanicolaou Smear…” Illinois HMO Contract, pages 40-42

“4.30 Miscellaneous
The HMO may provide reimbursement for abortions only in the following situations:
(1) the pregnancy is the result of an act of rape or incest; or
(2) the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.
No other abortions, regardless of funding, can be provided as a Covered Service under this Contract…” Iowa Contract, page 40.

IABH

“III. Substance Abuse Services
A. Women and Children Programs (Proposal Section 7A.2.2)
Under the Iowa Plan, coordination and integration of services for substance abusing women and their children will be enhanced as follows: ...
2. Since children may need services and supports funded under the Iowa Plan, the joint treatment planning process can generate a family plan that incorporates individual planning elements for mothers and their children.
3. Through the Women and Children Programs, supportive services such as…parenting skills development will be funded, as needed, to enhance the mother’s recovery…” Iowa Behavioral Health Contract, page 56.

“B. MEDICAL SERVICES NOT INCLUDED IN THE CONTRACT
The following services are non-covered under the terms of this contract, but are covered under Fee-For-Service in the Medicaid Program: ...
* Sterilizations and abortions...” Kansas Contract, page 3.

“10.09.67.27...
.27 Benefits-Limitations.
A. An MCO is not required to provide any of the benefits or services listed in §B of this regulation.

B. The benefits or services not required to be provided under §A of this regulation are as follows: …
(16) Abortions...
(19) In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures...
(34) Ovulation stimulants administered orally or parenterally...
(38) Abortions for women who have been determined eligible for Medical Assistance benefits under COMAR 10.09.28.”
Maryland COMAR 10.09.67.27.

“10.09.67 Maryland Medicaid Managed Care Program: Benefits
.27 Benefits-Limitations
B. The benefits or services not required to be provided under §A of this regulation are as follows: ...
(38) Abortions for women who have been determined eligible for Medical Assistance benefits under COMAR [10.09.28.]” Maryland COMAR 10.09.67.27, Proposed Regulation.

“Section 6.11. Services Not Covered By This Contract. Although the HEALTH PLAN may provide the following services, the prepaid capitation rate does not include payment for the following services, and therefore the HEALTH PLAN is not required to provide them…

Section 6.11.6. Fertility Drugs and Procedures. Fertility Drugs are not covered when
specifically used to enhance fertility. The following procedures also are not covered: in vitro fertilization, artificial insemination, and reversal of a voluntary sterilization.” Minnesota General Service, page 65.

“Section 6.22.1. Out of Network Services. The HEALTH PLAN shall cover Medically Necessary Out of Plan or Out of Area services received by an Enrollee when one of the following occurs...
F. Pregnancy-related services received in connection with an abortion.” Minnesota Contract, page 70.

“b. Covered Services...
The major types of out-of-plan services with which it must coordinate are described below:
4) Abortion services, subject to Medicaid program benefits and limitations, will be reimbursed by the State on a fee-for-service basis…” Missouri RFP, page 10.

“Health plans are responsible for ensuring the following core services are available to their members and for reimbursing the Department of Health and local health agencies according to the most current Medicaid fee schedule in effect at the time of service unless otherwise negotiated.
1) All sexually transmitted disease services including screening, diagnosis, and treatment...

STD screening diagnosis, and treatment services include:
Asexually transmitted disease screening exam.
* Screening, diagnosis and treatment for these sexually transmitted diseases: gonorrhea, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, genital herpes, genital warts, trichomoniasis, chlamydia (cervicitis), chlamydia (urethritis), hepatitis B, and others as may be designated by the state agency.
* Screening, diagnosis, and treatment of vaginal or urethral discharge including non-gonococcal urethritis and mucopurulent cervicitis.
* Evaluation and initiation of treatment of pelvic inflammatory disease (PID).
* Diagnosis and preventive treatment of health plan members who are reported as contacts/sex partners of any person and diagnosed with a sexually transmitted disease. The individual will be given the option of seeing a health plan provider first…” Missouri RFP, page 58.

“2.5.2 Non-Covered Services:
HMO NON-COVERED SERVICES/DESCRIPTION
Abortions/as defined by the DEPARTMENT.” Montana Contract, page 46.

“13.47.1 Family Planning Services Defined: Family planning services are services to prevent or delay pregnancy...This includes tubal ligations and vasectomy…” Nebraska Contract, page 96.

“CONTRACTOR DUTIES AND RESPONSIBILITIES
I. Medical Services
A. Contractor Mandatory Managed Care Benefit Package. Except as otherwise provided for in this contract, each Contractor must provide a comprehensive managed care benefit package to Medicaid participants…

B. Contractor Covered Services. At a minimum, the Contractor must provide directly or by subcontract all medical services listed below: ...
10. Family Planning…

H. Out-of-Plan Services. The Contractor benefit package includes Medicaid services for which the Contractor must reimburse for specific services, certain types of providers with whom formal contracts may not be in place. The Contractor must also coordinate these services with other services in the Contractor benefit package. The services/providers are as follows:

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. Family planning services are provided to persons who want to control family size or prevent unwanted pregnancies. Family planning services include education, counseling, physical examinations, birth control devices, supplies… Tubal ligations and vasectomies are included for individuals 21 years of age or older.

Tubal ligations and vasectomies to permanently prevent conception are not covered for anyone under the age of 21 who is adjudged mentally incompetent or who is institutionalized...” Nevada Contract, pages 21-25.

“Non-Covered Services and Limitations
A. Exclusions: the following are not covered:
Operations, devices, drugs and procedures for the purpose of contributing to or enhancing fertility or procreation.” New Hampshire General Agreement, Exhibit A.4., page 9.

“2.D.25 Pregnancy Termination Procedures:
The benefit package includes services for the termination of pregnancy and/or pre-or post-decision counseling or psychological services as set forth in Medical Assistance Division Program manual Section MAD-766, PREGNANCY TERMINATION PROCEDURES.” New Mexico Contract, page 41.

“2D.35.f The CONTRACTOR shall operate a Family Planning Program. This program shall ensure that members of the appropriate age of both sexes who seek Family Planning services shall be provided with counseling pertaining to the following: ... HIV and other sexually transmitted diseases and risk reduction practices; options for pregnant members who do not wish to keep a child; and options for pregnant members who may wish to terminate the pregnancy.” New Mexico Contract, page 50.

“6.25 Abortions
The HMO may provide for abortions only in the following situations:
* The pregnancy is the result of rape or incest;
* The woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.” North Carolina Contract, page 14.

“2.2 Provision of Covered Services...
(10) If the Contractor is owned, controlled, or sponsored by or affiliated with a religious institution or religious organization, and provision of or arrangement for a covered service(s) would violate the institution or organization’s religious or moral teachings and beliefs, the Contractor must notify the Department in writing which covered service(s) it will not directly provide or arrange. The Contractor is still financially responsible for those services. Per Section 2.15 of this attachment, the Contractor must notify enrollees of how to obtain the covered service(s).

(11) The Contractor must include, at a minimum, in its definition of high risk pregnant women, those women whose fetus has a significant increased risk of death or serious impairment, either before or after birth, due to the mother’s risk factors, including age extremes, adverse, adverse behavior, degree of literacy, physical or mental illness, depressed economic status, or previous prenatal history...

2.4 Family Planning Service Access and Confidentiality...
(4) Abortions are not covered service or a family planning service for purposes of this contract except as specifically permitted by North Dakota Law.” North Dakota Contract, Attachment C, pages 8-10.

“ATTACHMENT M: NON-COVERED SERVICES
The following services are NOT COVERED SERVICES under this contract:
1. Abortions except as defined by the Department...
The following are NOT COVERED SERVICES under Medicaid: ...
4. Reversal of sterilization.
5. In vitro fertilization and embryo transplantation or implantation.” North Dakota Contract, Attachment M.

“APPENDIX M
COVERED FAMILY PLANNING SERVICES
A. The following specified family planning services are covered if the services are provided
on-site by a qualified family planning provider (QFPP) in accordance with the Program Guidelines for Family Planning Services as issued by the U.S. Department of Health and Human Services:

(2) History and physical assessments/examinations provided for family planning purposes or for the diagnosis and treatment of sexually transmitted diseases (STDs);

(3) Laboratory procedures provided for family planning purposes; provided for the diagnosis of sexually transmitted diseases; or typically provided during routine gynecological examinations for women of child bearing ages (e.g., pap smears)...

(6) All pharmaceuticals currently covered under the Ohio Medicaid formulary which are prescribed for the treatment of a sexually transmitted disease.

B. The following specified family planning services are covered if the services are prescribed by a qualified family planning provider but are not available on-site, if the off site services are coordinated through the primary care physician (PCP) and provide by an MCP panel provider, or are coordinated through the PCP and provided in accordance with a pre-approved arrangement between the MCP and the QFPP:

(1) Laboratory procedures authorized for family planning purposes, provided for the diagnosis of sexually transmitted diseases, or typically provide during routine gynecological examinations for women of child bearing ages (e.g., pap smears)...

(3) All pharmaceuticals currently covered under the Ohio Medicaid formulary which are prescribed for the treatment of a sexually transmitted disease.” Ohio RFP, Appendix M, pages 1-2.

“2.5.8 Abortion Services
Health Plan may only provide abortions in the following situations:
* If the pregnancy is the result of rape or incest; or
* If the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.
No other abortions can be provided as a benefit under the Health Plan…” Oklahoma RFP, page 30.

“3. STATEMENT OF WORK
A. Subject to the provisions of this Section and Section 4, COVERED SERVICES...
Contractor shall:

(1) (a) Ensure provision of Medically Appropriate Covered Services consistent with OAR 410-141-0120, including
Emergency Services and preventive care services, in all those categories listed below as Mandatory and in those Optional categories that are listed below (hereinafter referred to as Capitated Services) for all OMAP Members: …

Outpatient Hospital/ASC - Sterilization
Outpatient Hospital/ASC - Hysterectomy...
Prescription Drugs - Family Planning...
Inpatient Hospital - Hystrectomy...
Inpatient Hospital - Sterilization…” Oregon Contract, pages 2-3.

“K. Sterilizations and Hysterectomies
(1) Sterilizations are a Covered Service only when they meet the federally mandated criteria...
(2) Hysterectomies are a Covered Service only when provided for medical reasons unrelated to sterilization…” Oregon Contract, page 10.

“EXTENDED FAMILY PLANNING BENEFITS...
Procedures
Covered benefits are limited to the following office/clinic/outpatient procedures if indicated:
* Colposcopy, and cryosurgery or other cauterization of the cervix
* Tubal ligation
* Treatment for genital warts…
* Incision and drainage of a Bartholin’s gland cyst or abscess...” Rhode Island RFP, Attachment F, page 1.

“2-3. Benefits/Service Requirements and Limitations…
r. Coverage of Sterilizations, Abortions and Hysterectomies
The CONTRACTOR shall cover sterilizations, abortions and hysterectomies pursuant to applicable federal and state laws and regulations. When coverage requires the completion of a specific form, the form must be properly completed as described in the instructions with the original form maintained in the enrollee’s medical file and a copy submitted to the CONTRACTOR for retention in the event of audit...

The following are applicable current policies:
1. Sterilizations
(a) Sterilization shall mean any medical procedure, treatment or operation done for the purpose of rendering an individual permanently incapable of reproducing.
(b) The individual to be sterilized shall give informed consent not less than thirty (30) full calendar days (or not less than 72 hours in the case of premature delivery or emergency abdominal surgery) but not more than one hundred eighty (180) calendar days before the date of the sterilization.
(c) The individual to be sterilized is at least twenty-one (21) years old at the time consent is obtained.
(d) The individual to be sterilized is mentally competent...

2. Abortions
(a) Abortion and services associated with the abortion procedure shall be covered only when the life of the mother would be endangered if the fetus were carried to term or if the pregnancy is the result of an act of rape or incest.
(b) A ‘CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION’ form, contained in this Agreement as
Attachment VII, must be completed.

3. Hysterectomy
(a) Hysterectomy shall be covered when medically necessary...
(d) Hysterectomy shall not be covered if performed solely for the purpose of rendering an individual permanently incapable of reproducing.
(e) Hysterectomy shall not be covered if there was more than one purpose for performing the hysterectomy, but the primary purpose was to render the individual permanently incapable of reproducing.
(f) Hysterectomy shall not be covered if it was performed for the purpose of cancer prophylaxis.” Tennessee Contract, pages 7-27.

“Attachment C - Covered Services
D. General Preventive Services
The CONTRACTOR must develop or adopt practice guidelines consistent with current standards of care...
A minimum of three screening programs for prevention or early intervention (e.g. Pap Smear …)” Utah Contract, Attachment C, pages 1-2.

“O. Abortions and Sterilizations
These services are provided to the extent permitted by Federal and State law and must meet the documentation requirement of 42 CFR 441, Subparts E and F. These requirements must be met regardless of whether Medicaid is primary or secondary payer…” Utah Contract, Attachment C, page 4.

“9. Family Planning Services and Supplies...
The Contractor shall ensure that the consent form of 42 C.F.R. § 441.259 is both obtained and documented prior to the performance of any sterilization under this Contract. The Contractor shall not perform a sterilization for an enrollee under age twenty-one (21). The Contractor shall comply with the requirements set forth in 42 C.F.R § 441, Subpart F, as amended, and shall comply with the thirty (30) calendar day waiting period requirement as specified in Code of Virginia, § 54.1-2974.” Virginia Contract, pages 44-45.

“32. Women’s Health Care Services
(a). The Contractor shall permit any female recipient of age thirteen (13) or older direct access, as provided in subsection B of § 38.2-3407.11 of the Code of Virginia, to a participating obstetrician -gynecologist for annual examinations and routine health care services including pap smears without prior authorization from the primary care physician. Health care services means the full scope of medically necessary services provided by the obstetrician-gynecologist in the care of or related to the female reproductive system in accordance with the most current published recommendations of the American College of Obstetricians and Gynecologists.
(b). The Contractor shall cover mammograms for female enrollees age thirty-five (35) and over...
(c). The Contractor shall cover breast prostheses following medically necessary removal of a breast for any medical reason...
(d). The Contractor shall provide coverage for at least a 48-hour hospital stay following a radical or modified radical mastectomy and not less than 24 hour of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for the treatment of breast cancer…
(e). The Contractor shall cover reconstructive breast surgery…” Virginia Contract, pages 52-53.

“33. Medallion II Carved-Out Services
(a) The Contractor is not required to cover Medallion II carved-out services...
(b) The following services are Medallion II carved-out services: ...
(6) Abortions as set forth in 12 VAC 30-50-180 and 42 C.F.R. § 441.203 and § 441.206.” Virginia Contract, page 55.

“Medallion II, Article II.G.2., Page 37 and Options, Article II.G.2., Page 35 Abortions: Revise as follows:
Under the terms of this contract, the Contractor shall not cover services for abortion, as detailed in Attachment II of ‘Covered Services.’…” Virginia Contract, Addendum #3.

“EXCLUSIONS
The following services and supplies are excluded from coverage under this agreement. This shall not be construed to prevent the Contractor from covering any of these services when the Contractor determines it is medically necessary…

SERVICES COVERED BY MAA FEE-FOR-SERVICE OR THROUGH SELECTIVE CONTRACTS: ...
* Voluntary Termination of Pregnancy, including complications…” Washington Contract, Exhibit 6, Attachment 1, pages 5, 6.

“3.2 Coordination and Continuation of Care
The Managed Care Plan shall have systems in place to ensure well-managed patient care, including at a minimum: ...
* a system by which enrollees may obtain a covered service or services that the Managed Care Plan does not provide or for which the Managed Care Plan does not arrange because it would violate a religious or moral teaching of the religious institution or organization by which the Managed Care plan is owned, controlled, sponsored or affiliated…

3.9 Family Planning Access and Confidentiality...
Family planning services are defined as the following: ...
* limited history and physical examination;
* laboratory test if medically indicated as part of decision making process for choice of contraceptive methods...
* follow-up care for complications associated with contraceptive methods issued by the family planning provider...
* pregnancy testing and counseling.” West Virginia Contract, pages 7, 13.

“Exhibit A...
HMO Covered Services...
The HMO must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services...

MEDICAL SERVICE…/SCOPE OF BENEFITS/LIMITATION ON SERVICES
Abortion/Drugs or devices to prevent implantation of the fertilized ovum and for medical procedures necessary for the termination of an ectopic pregnancy./Written physician certification of medical necessity. All federal and state laws regarding this benefit must be adhered to.” West Virginia Contract, Exhibit A, page 1.

“MCP Covered Services
The following charts present an explanation of the medical services which the MCP is required to provide... The MCP must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services….

MEDICAL SERVICE/ SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Abortion/Drugs or devices to prevent implantation of the fertilize ovum and for medical procedures necessary for the termination of an ectopic pregnancy./ Written physician certification of medical necessity. All federal and state laws regarding this benefit must be adhered to.” West Virginia RFA, Appendix A, page A1.

“III. FUNCTIONS AND DUTIES OF THE HMO
In consideration of the functions and duties of the Department contained in this Contract the HMO shall: ...

B. PROVISION OF CONTRACT SERVICES...
12… None of the provisions of this contract that are applicable to Wisconsin Medicaid covered services apply to other services
that an HMO may choose to provide, except that abortions, hysterectomies and sterilization’s must comply with 42 CFR 441 Subpart E and 42 CFR 441 Subpart F.” Wisconsin Contract, pages 5, 11.

“00. LIMITATION ON FERTILITY ENHANCING DRUGS - The HMO must get prior authorization from the Chief Medical Officer in the Bureau of Health Care Financing before an HMO provider treats an enrollee with any of the following drug products: Chronic Gonadotropin, Clomiphene, Gonadorelin, Menotropins, Urofollitropin and any other new fertility enhancing drugs.” Wisconsin Contract, page 38.