10 Colo. Code Regs. § 2505-10-8.730

Current through Register Vol. 47, No. 11, June 10, 2024

Section 10 CCR 2505-10-8.730 - FAMILY PLANNING SERVICES

8.730.1Definitions

Family Planning Services mean those services provided to individuals of child-bearing age, including sexually active minors, where the intent of that service is to delay, prevent, or plan for a pregnancy. Family Planning Services may include physical examinations, evaluation, treatments, counseling, supplies, prescriptions, and follow-up services.

Institutionalized Individual means an individual who is (a) involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility (including a psychiatric hospital or other facility) for the care and treatment of a mental illness; or (b) confined, under a voluntary commitment in a psychiatric hospital or other facility, for the care and treatment of a mental illness.

Mentally Incompetent Individual means an individual who has been declared mentally incompetent by a federal, state, or local court for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.

Sterilization means any medical procedure, treatment, or operation (except for a hysterectomy) for the purpose of rendering an individual permanently incapable of reproducing and that requires informed consent

8.730.2Client Eligibility

8.730.2.A. All Medicaid clients of childbearing age are eligible for family planning services.

8.730.3Provider Eligibility

8.730.3.A. The following Medicaid enrolled providers may offer family planning services:

1. Physician

2. Osteopath

3. Nurse Practitioner

4. Certified Nurse-Midwife

5. Physician Assistant

6. Clinical Nurse Specialist

7. Certified Registered Nurse Anesthetist

8. Family Planning Clinic

9. Public Health Agency

10. Non-physician Practitioner Group

8.730.3.B. Eligible places of service include:

1. Office

2. Clinic

3. Public Health Agency

4. Home

5. School

6. School-based Health Center

7. Federally Qualified Health Center

8. Rural Health Center

9. Hospital

10. Ambulatory Surgery Center

11. Telemedicine may be provided in accordance with Section 8.095.

8.730.4Covered Services

8.730.4.A. Office Visits

1. A comprehensive, annual family planning visit (where the intent of the visit is related to pregnancy prevention or planning) is covered only once per state fiscal year, no less than ten months apart, and may include: physical examinations, evaluation, treatments, counseling, supplies, contraceptives and prescriptions. Additional family planning follow-up visits and services are covered when medically necessary.

8.730.4.B. Sterilization

1. Sterilization is covered for a client who is:

a. 21 years of age or older;

b. Is mentally competent;

c. Is not institutionalized; and,

d. Has given written informed consent where at least one of the following conditions apply:

i. At least 30 days, but no more than 180 days have passed between the date of informed consent and the date of sterilization;

ii. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery and at least 72 hours have passed since the date of informed consent; or

iii. In the case of emergency abdominal surgery, at least 72 hours have passed since the date of informed consent.

2. A client with an intellectual and developmental disability is protected under C.R.S. 25.5-10-231 and C.R.S. 25.5-10-232 with respect to sterilization rights and competency to give consent for sterilization.

a. The above statutes are applicable except for clients aged between eighteen and twenty-one years. For any signed sterilization consent to be considered valid, any client, including those with an intellectual and developmental disability, is required to be 21 years or older.

8.730.4.C. Contraceptives

1. All FDA-approved contraceptives, including emergency contraceptives, are a covered benefit.

8.730.5Documentation

8.730.5.A. Services

1. For family planning services and supplies, the provider shall document the intention of the service as it relates to delay, prevention, or for planning a pregnancy.

8.730.5.B. Sterilization Consent Form

1. Submission of a valid signed sterilization consent form is required prior to reimbursement. The sterilization consent form shall be signed and dated by:

a. The client to be sterilized;

b. The interpreter, if one was provided;

c. The person who obtained the consent; and

d. The physician who will perform the sterilization procedure.

2. If an interpreter is provided, the interpreter shall, by signing the consent form, certify that he or she translated the information presented orally, read the consent form and explained its contents to the client, and that, to the best of the interpreter's knowledge, the client understood the information provided.

3. The person who obtained the consent shall, by signing the consent form, certify that he or she provided the client with all of the information set forth in 8.730.5.B.6. and, to the best of his or her knowledge, the client appeared mentally competent, and knowingly and voluntarily consented to be sterilized.

4. The physician performing the sterilization shall, by signing the consent form, certify that:

a. He or she provided the client with all of the information set forth in 8.730.5.B.6;

b. To the best of his or her knowledge the client appeared mentally competent, and knowingly and voluntarily consented to be sterilized;

c. Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days but less than 180 days have passed between the date of the client's signature on the consent form and the date upon which the sterilization was performed;

d. In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days, but more than 72 hours, after informed consent was obtained because of premature delivery or emergency abdominal surgery; and,

e. In the case of premature delivery, the physician shall state the expected date of delivery, or in the case of emergency abdominal surgery, the physician shall describe the emergency.

5. Informed consent for sterilization cannot be obtained when a client is:

a. In labor or childbirth;

b. Seeking to obtain or obtaining an abortion; or

c. Under the influence of substances that impair the individual's decision making capabilities.

6. Informed consent is valid only when the client has been offered and given:

a. Answers to any questions concerning the procedure;

b. A copy of the consent form;

c. A copy of the signed consent form; and,

d. Orally provided the following information:

i. The ability to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the client might otherwise be entitled.

ii. A description of available alternative methods of family planning and birth control.

iii. That the sterilization procedure is considered to be irreversible.

iv. An explanation of the specific sterilization procedure to be performed.

v. A description of the discomforts and risks that may accompany or follow the sterilization procedure including an explanation of the type and possible effects of any anesthetic to be used.

vi. A description of the benefits or advantages that may be expected as a result of the sterilization.

vii. That the sterilization will not be performed for at least 30 days but less than 180 days from consent except under the circumstances specified in 8.730.4.B.1.d.ii, or 8.730.4.B.1.d.iii.

7. The consent is not valid unless the information specified in 8.730.5.B.6. is effectively communicated to any client who is blind, deaf, or otherwise disabled.

8. An interpreter shall be provided if the client to be sterilized does not understand the language used on the consent form or the language used by the person obtaining consent.

9. The client to be sterilized may have a witness of his or her choice present when consenting to the procedure.

8.730.6.Non-covered Services

8.730.6.A. The following services are not covered benefits for Medicaid clients:

1. Sterilization reversal

2. Infertility treatment and testing

8.730.7.Prior Authorization

8.730.7.A. Prior authorization is not required for family planning services.

8.730.8.Reimbursement

8.730.8.A. Reimbursement for family planning services requires an appropriate Family Planning diagnostic code along with use of the family planning (FP) modifier.

10 CCR 2505-10-8.730