North Carolina Be Smart Family Planning Waiver Program
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1 North Carolina Be Smart Family Planning Waiver Program First Time Motherhood/New Parent Initiative EDGECOMBE GATES HALIFAX HERTFORD NASH NORTHAMPTON 1
2 Purpose of the Family Planning Waiver (FPW) To reduce unintended pregnancies and improve the well being of children and families in North Carolina by extending eligibility. FPW Special Bulletin, p.1 2
3 BENEFITS Reaches peoples otherwise not being served Improves birth spacing Can significantly lower the number of: Perinatal complications Infant mortality Babies born Prematurely / low birth weight With birth defects Medical complications Child abuse and/or neglect Abortions Recruitment of Family Planning Waiver patients should result in increased Title X slots for patients, including the uninsured, at the Local Health Departments 3
4 Eligible Recipients Women age Men age Income at or below 185% federal poverty level U.S. citizens or documented immigrants Residents of North Carolina Not incarcerated Not pregnant Not permanently sterilized, or unable to have children Not on Medicare FPW Special Bulletin, p.3 4
5 Eligibility Determination Potential enrollees cannot choose the Medicaid Family Planning Waiver State first must determine if eligible under a more comprehensive Medicaid coverage category No auto eligibility No presumptive eligibility Can receive three months retroactive coverage Family and Children s Eligibility Manual MA 3265, Medicaid Family Planning Waiver 5
6 Services Offered Exams (including counseling and education) Laboratory procedures Medically approved methods, procedures, pharmaceutical supplies, and devices to prevent contraception Voluntary sterilization FPW Special Bulletin, p.5 6
7 Service Limits Only specific family planning services and supplies covered New family planning methods and services must be approved by the Centers for Medicare and Medicaid Services (CMS) Services must be performed within the scope of a family planning office visit 7
8 Non Covered Services Abortions Ambulance Dental Durable Medical Equipment Infertility Services Inpatient Hospital Services Mental Health FPW Special Bulletin, p.5 8
9 Non Covered Services (cont.) Optical AIDS Treatment Cancer Treatment Sick Visits Medical conditions/problems discovered during a screening Medical conditions/problems caused by or following a family planning procedure FPW Special Bulletin, p.5 9
10 Service Providers Local Health Departments Federally Qualified Health Centers Ambulatory Surgery Centers Rural Health Clinics Physicians Nurse Practitioners Nurse Midwives Certified Registered Nurse Anesthetists Laboratories Outpatient Hospitals FPW Special Bulletin, p.2 10
11 Annual Examinations Must be performed for all waiver recipients before any other waiver services can be provided Limited to one per 365 days FPW Special Bulletin, p.7 11
12 Periodic Visit Follow up Office After Hours Six per 365 days FPW Special Bulletin, p.14 12
13 Laboratory Procedures Pregnancy Test Urinalysis Blood Count Pap Smear HIV Screening STI Screening FPW Special Bulletin, p.9 13
14 Laboratory Procedures One allowed in conjunction with an annual exam Note: in conjunction date of procedure or up to 30 days after (Example: July 2, 2006 you have until Aug. 1, 2006) Exception to in conjunction rule pregnancy tests FPW Special Bulletin, p.8 14
15 Pregnancy Tests Allowed during annual exam, periodic visit, office after hours, sterilization consultation, and sterilization pre operative Total of 7 pregnancy tests allowed per 365 days FPW Special Bulletin, p.9 15
16 STI Treatment One course of approved antibiotics for each organism Approved antibiotic list can be found in the N.C. Medicaid Special Bulletin, Attachment C, May 2006 FPW Special Bulletin, p.14 & Attachment C 16
17 Sterilizations Providers must adhere to all federal guidelines. One per lifetime NC Medicaid does not cover reversals Two office consultations per lifetime Covers outpatient sterilization only FPW Special Bulletin, p.16 17
18 Covered Contraceptives FDA approved and Medicaid covered Pharmaceutical supplies No brand medically necessary if generic available FPW Special Bulletin, p.20 18
19 Covered Contraceptives Diaphragm Fitting Injectable drugs I.U.D. Norplant Removal Mirena Nuva Ring Birth Control Pills Ortho Evra. Emergency Contraceptives FPW Special Bulletin, pgs
20 Referrals Outside scope of FPW Safety Net providers: NCsafetynetorglist.html FPW Special Bulletin, p
21 FPW Medicaid Card 21
22 22
23 FPW Billing Tips All services must be billed with the appropriate: CPT/HCPCS code ICD 9 CM diagnosis and FP modifier Providers must select the most appropriate codes for services rendered under the Family Planning Waiver and adhere to all the components of the code as defined by the American Medical Association. The annual exam date (AED) must be entered in block 15 on the CMS Providers must include the AED on all claims for an annual examination and laboratory procedures, except pregnancy tests. 23
24 FPW Billing Tips An ICD 9 CM diagnosis related to family planning services must be the primary diagnosis on the claim form. See the May 2006 Medicaid Special Bulletin, Family Planning Waiver, for a complete list of codes which can be used. All approved antibiotic treatment and pain medications must have the appropriate ICD 9 CM diagnosis written on the prescription. No brand medically necessary (DAW1) medications are allowed, if a generic is available. All applicable North Carolina Medicaid policies and procedures must be adhered to in addition to those listed in the special bulletin. 24
25 FPW Billing Tips Federally Qualified Health Centers/Rural Health Clinics All FQHC/RHC providers must bill using the C suffix provider number. The core service code is not allowed with Family Planning Waiver services. Local Health Departments Indicate Yes on the HSIS Service Screen data field for Family Planning Waiver Services 25
26 FPW Billing Tips Outpatient Hospitals All services must be billed with the appropriate Revenue code, CPT code and ICD 9 CM diagnosis. All laboratories services must be billed with the appropriate laboratory revenue code and HCPCS code. Hospital providers must use the occurrence form locators 32, 33, 34, or 35. Enter an 11 in the occurrence code field and then enter the AED in the corresponding date field. 26
27 FPW Billing Tips Pharmacy (Outpatient Only) All eligible drugs will have a family planning indicator on the drug file (including birth control pills, Depoprovera, Ortho Evra). All claims must be submitted via point of sale with the approved ICD 9 CM diagnosis written on the prescription. Dispensing fee based on Medicaid rules. 27
28 Automated Voice Response System Up to 15 inquiries per call Check claim status, checkwrite information, prior approval, and recipient eligibility 28
29 Contacting EDS Call or Press 1 Electronic Commerce Services Press 2 Prior Approval Press 3 Provider Services Press 4 Operator 29
30 FPW YEAR ONE EVALUATION 26,039 females and 5,560 males were enrolled (5.2% enrollment rate for females and 1.3% for males). Among enrollees, 9,819 females and 99 males received services (participation rate 37.7% females, and males 1.8%). FPW was budget neutral. Average participant cost was $192. Reduced costs associated with 876 births averted for the first year offset FPW costs by an estimated $9.5 million. 30
31 FPW YEAR 2 INTERIM EVALUATION 41,520 females and 7,873 males enrolled (includes both new enrollees and enrollees continuing from Year One). Average costs per participant for was approximately $267. Estimated averted births range of 1,435 1,652. FPW expenditures were $4.3 million. Estimated net savings to the state of North Carolina $14.3 $17.1 million. 31
32 How to Apply Health Check/Health Choice Application Local Department of Social Services Local Health Departments Federally Funded Community Health Centers On Line Application Application processing period: 45 days 32
33 Be Smart Informational Materials Posters Brochures Fact Sheet Available at: NC Healthy Start Foundation or by calling the Family Health Resource Line at
34 FPW Brochures 34
35 Informative Posters 35
36 Outreach Materials Order Form 36
37 FPW Information For more information about the North Carolina Medicaid Family Planning Waiver, visit the following links: Division of Medical Assistance Webpage May 2006 Medicaid Special Bulletin, Family Planning Waiver Family and Children s Eligibility Manual, MA 3265 Medicaid Family Planning Waiver Waiver Year One Interim Annual Report 37
38 DHHS FPW Program Managers NC Dept. of Health & Human Services Division of Medical Assistance Division of Public Health contact information: DMA DPH Tysha Grays Marcia Swartz FPW Project Manager FPW Project Manager (919) (919) (919) Fax (919) Fax
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