The new Indiana Medicaid Family Planning Program may leave some providers holding the bill for non-covered services.
The new program which began January 1, 2013, covers otherwise non-eligible participants who fall at or below 133% of the federal poverty line for services designed to prevent or delay pregnancy, such as family planning visits, lab tests indicated to determine contraceptive methods, pap smears, initial diagnosis and treatment of sexually transmitted diseases and infections (STDs), tubal ligations, and vasectomies.
Other services, however, such as abortion, artificial insemination or other fertility treatments, inpatient hospital stays, reversal of sterilization procedures, chronic treatment of STDs, or services unrelated to family planning are not covered.
Because the Family Planning Program falls under the traditional Medicaid program, in order for participating Medicaid providers to bill patients for any service not covered under their Family Planning Program insurance, they must have the patient sign a waiver before receiving the service acknowledging that the patient understands that the service is not covered by Medicaid and also that he voluntarily chose to receive the service knowing he would be financially responsible.
This pre-service eligibility verification and waiver process becomes overly burdensome to many emergency physician groups who must see and treat patients regardless of insurance status. Since verifying eligibility and obtaining a waiver is often not feasible in the fast-paced emergency department setting, those providers are left with no recourse for payment from Medicaid or the patient directly under the Indiana Health Coverage Programs (IHCP) guidelines (see pages 57-59 of Chapter 4 of the Provider Manual).
This same burden may affect other hospital-based physicians or mid-level practitioners providing anesthesia, surgeries, consultations, etc. to Family Planning Program participants when time or processing does not allow for a thorough verification of eligibility or benefits in order to properly and efficiently treat patients.
Selected covered services may also be denied if prior authorization is not received, if consent forms are not obtained (for sterilization services – see page 4 of IHCP bulletin BT201301), or if family planning diagnoses only are not listed in each slot of physician claims or in the primary position for outpatient claims.
Explanation of Benefits codes 2057, 2058, 2059, and 2060 indicate denials for physician claims with diagnoses not on the Family Planning list, for outpatient non-family planning procedures or a non-family planning diagnosis in the primary position, for non-covered inpatient or long-term care claims, or for non-covered home health or dental claims, respectively. (See page 2 of IHCP bulletin BT201303.)
Individuals interested in requesting a policy change to this or other Medicaid policies can complete and submit a “Request for Policy Consideration” form located on the IHCP website.
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