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Ohio Laws and Rules
(A) Sterilization procedures will be reimbursed only if the following requirements are met:
(1) The sterilization must be the result of a voluntary request for such services by a recipient legally capable of consenting to such a procedure.
(2) The individual is at least twenty-one years old at the time consent is obtained.
(3) The individual is not mentally incompetent. For program purposes, “mentally incompetent individual” is defined as a person who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.
(4) The individual is not institutionalized. For program purposes, “institutionalized individual” is defined as an individual who is:
(a) Involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or
(b) Confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness.
(5) The individual has been given a thorough explanation of all elements of the department’s approved “Consent to Sterilization Form” JFS 03198, contained in appendix A of this rule, prior to giving consent for the procedure to be performed. In addition, the recipient must have been made fully aware that he/she is free to withhold 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 individual might be otherwise entitled. In instances where the individual is blind, deaf, or otherwise handicapped, arrangements must be made to ensure that all information is effectively communicated. Similarly, an interpreter must be provided if the individual to be sterilized did not understand the language of the consent form or of the person obtaining the consent. The individual must also be permitted to have a witness of his/her choice present when consent is made.
(6) At least thirty days, but not more than one hundred eighty days, have passed between the date of the informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least seventy-two hours have passed since he/she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least thirty days before the expected date of delivery. It should be noted that the above waiver does not apply to cases of unanticipated abortions, since, unlike situations involving emergency abdominal surgery or premature delivery, an abortion in the first trimester of pregnancy is not generally considered a major surgical procedure with consequent double exposure to the risks of major surgery.
(B) Informed consent must be obtained on either the consent form located at the back of the sterilization pamphlets published by the U.S. government printing office, or the department’s “Consent to Sterilization Form” JFS 03198. The primary physician performing the sterilization is normally responsible for securing the recipient’s informed consent for the procedure; however, should a recipient change physicians between the time a physician secures the recipient’s consent and the date of the sterilization, it is not necessary for the physician performing the sterilization procedure to complete a second consent form if the initial consent form is available. However, all invoices submitted to the department for sterilization, whether performed as a primary or secondary procedure, or for medical procedures directly related to such sterilizations, must include a copy of the signed consent form. Reimbursement will not be made for associated services when the sterilization procedure itself is not eligible for reimbursement, regardless of whether or not the procedure is itself billed to the department. The physician may sign and date the consent to sterilization form either before or after the date the procedure is performed. The date the physician signs the form cannot be prior to the date that the recipient signs the form. Informed consent must not be obtained while the individual to be sterilized is:
(1) In labor or childbirth; or
(2) Seeking to obtain or obtaining an abortion; or
(3) Under the influence of alcohol or other substances that affect the individual’s state of awareness.
(C) Sterilization by hysterectomy.
(1) Reimbursement cannot be made for hysterectomy procedures when the primary intent of the hysterectomy is for fertility control. Payment will only be made for those hysterectomies performed for medical reasons, such as a diseased uterus, and only if the recipient has been advised orally and in writing prior to surgery that sterility will result. Acknowledgment of the receipt of this information must be obtained by completing section II of the department’s approved “Consent to Hysterectomy” form JFS 03199 contained in appendix B of this rule. The primary physician performing the hysterectomy is normally responsible for securing the recipient’s consent to the procedure. Should a recipient change physicians between the time a physician secures the recipient’s consent and the date of the sterilization, it is not necessary for the physician performing the sterilization procedure to complete a second consent form if the initial consent form is available. However, as in the case of sterilizations, all invoices submitted to the department for hysterectomies, whether performed as a primary or secondary procedure, or for medical procedures directly related to such hysterectomies, must include a copy of the signed approved hysterectomy consent form. Reimbursement will not be made for associated services when the hysterectomy procedure itself is not eligible for reimbursement, regardless of whether or not the hysterectomy procedure is itself billed to the department. The recipient may sign the consent form either before or after the surgery as long as she was informed of the consequences of the procedure orally and in writing prior to surgery.
(2) Payment can be made for a hysterectomy without obtaining signed acknowledgment of the hysterectomy consent form in the following circumstances:
(a) The individual was already sterile before the hysterectomy; or
(b) The individual was postmenopause; or
(c) The individual requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that prior acknowledgment is not possible.
In either situation, where the exceptions apply, a physician meeting the conditions specified in paragraph (C)(1) of this rule must certify by completing section III on the JFS 03199 that the individual was already sterile at the time of the hysterectomy and state the cause of the sterility; or, certify that the hysterectomy was performed under a life-threatening emergency situation in which the physician determined that prior acknowledgment was not possible. The primary physician must also include a description of the nature of the emergency.
(3) Reimbursement is also available for hysterectomies performed during a period of an individual’s retroactive eligibility if the physician certifies that all the requirements are met by completing section IV on the JFS 03199. In a case where signed acknowledgment by the recipient or her representative is required, section II of the JFS 03199 must also be completed.
(4) If a recipient requiring a hysterectomy is eligible for both medicaid and medicare, an acknowledgment statement or certification of exception must be obtained. The properly completed JFS 03199 form must not be attached to the medicare claim form, but must be forwarded separately to the department. If the claim is rejected by medicare, the provider should submit a separate invoice to the department with the medicare rejection attached. The date that the JFS 03199 form was sent to the department should be entered in the provider remarks section of the medicaid invoice.
(D) All claims for both sterilizations and sterilizations by hysterectomy must be billed on an invoice. No electronic claims will be accepted.
Invoices received for both sterilization and sterilization by hysterectomy must comply with the requirements of this rule if they are to be eligible for reimbursement. Invoices that are not in compliance with the requirements of this rule will be denied and returned to providers.
Appendix A Consent Form
Notice: Your decision at any time not to be sterilized will not result in the withdrawal or withholding of any benef provided by programs or projects receiving federal funds.
Consent to sterilization
I have asked for and received information about sterilization from ________________________.(doctor or clinic)
When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as ???F.D.C. or Medicaid that I am not getting or for which I may become eligible.
I understand that the sterilization must be considered permanent and not reversible. I have decided that I do not want to become pregnant, bear children or father children.
I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father or child in the future. I have rejected these alternatives and chosen to be sterilized.
I understand that I will be sterilized by an operation known as a __________________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction.
I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs.
I am at least 21 years of age and was born on __________________________. Month Day Year
________________________________________, hereby consent of my own free will to be sterilized by ________________________________________ (doctor) by a method called ________________________________. My consent expires 180 days from the date of my signature below.
I also consent to the release of this form and other medical records about the operation to:
Representatives of the Department of Health, Education, and Welfare or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed.
I have received a copy of this form.
Date: __________________________ ___________________________________
Signature Month Day Year
You are requested to supply the following information, but it is not required:
Race and ethnicity designation (please check)
American Indian or [ ] Black (not of Hispanic origin)
Alaska Native [ ] Hispanic
Asian or Pacific Islander [ ] White (not of Hispanic origin)
Interpreter’s statement
If an interpreter is provided to assist the individual to be sterilized:
I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in ___________________________ language and explained the contents to him/her. To the best of my knowledge and belief he/she understood this explanation.
Statement of person obtaining consent
Before ______________________________________ name of individual
signed the consent form, I explained to him/her the nature of the sterilization opera ________________________, the fact that it is intended to be a final irreversible procedure and the discomforts, risks and benefits associated with it.
I counseled the individual to be sterilized that alternative methods of b control are available which are temporary. I explained that sterilization different because it is permanent.
I informed the individual to be sterilized that his/her consent can withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds.
To the best of my knowledge the belief the individual to be sterilized i least 21 years old and appears mentally competent. He/She knowingly voluntarily requested to be sterilized and appears to understand the nature consequences of the procedure.
Signature of person obtaining consent Date
Facility
Address
Physician’s statement
Shortly before I performed a sterilization operation upon on ______________________________________ Name of individual to be sterlized ____________________________________ Date of sterlization
I explained to him/her, the nature of ____________________________________________________________ operation specify type of operation
the fact that it is intended to be a final and irreversible procedure and the discomfo risks and benefits associated with it.
I counseled the individual to be sterilized that the alternative method birth control are available which are temporary. I explained that sterilizatio different because it is permanent.
I informed the individual to be sterilized that his/her consent can withdrawn at any time and that he/she will not lose any health services benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be sterilized i least 21 years old and appears mentally competent. He/She knowingly voluntarily requested to be sterilized and appeared to understand the nature consequences of the procedure.
(Instructions for use of alternative final paragraphs: Use the paragraph below except in the case of premature delivery or emerge abdominal surgery where the sterilization if performed less than 30 days a the date of the individual’s signature on the consent form. In those cases, second paragraph below must be used. Cross out the paragraph which is used.)
(1) At least thirty days have passed between the date of the individu signature on this consent form and the date the sterilization was performe
(2) This sterilization was performed less than 30 days but more than hours after the date of the individual’s signature on this consent form beca of the following circumstances (check applicable box and fill in informa requested):
[ ] Premature delivery
[ ] Individual’s expected date of delivery:
[ ] Emergency abdominal surgery:(describe circumstances):
_________________________________________________________________________________ Physician’s Name
Date ___________________
Distribution: Original to patient; one copy retained by physician; one copy retained by anesthesiologist; once copy to ODJFS.) JFS 03198 (Rev. 10/2003)
Appendix B Ohio Department of Job & Family Services
Consent to hysterectomy
Note: Type of print clearly .
Section I: Identifying Information
Patient’s Name Physician’s Name
Medicaid Number Provider Number(7-digit)
Date of Surgery Physician’s Signature
Section II. Consent (If consent is not required, go on the Section III.)
I understand that this hysterectomy, whether performed as a single procedure or together with other procedures, is medically necessary and is not to be performed solely for family planning purposes.
The fact that the surgery will make me permanently incapable of bearing children in the future has been explained to me orally and in writing.
[ ] Consent before surgery – I understand the above statements.
[ ] Consent after surgery – I understand the above statements. The were explained to me orally and in writing before surgery.
Patient/Representative Signature Date of Signature Person Obtaining Consent(if other than physician)
Sections III: Exceptions
[ ] 1. Prior Sterility, explain: _______________________________________________________________________________________.
[ ] 2. Post menopause age ________________________________.
[ ] 3. Patient required a hysterectomy because of a life-threatening emergency in which prior consent was not possible. Explain emergency:
Section IV: Retroactive Eligibility
At time of the hysterectomy Medicaid eligibility was not established. For retroactive payment check boxes that apply and complete information requested.
[ ] 1. Patient was informed of the consequences of the procedure and has signed the consent form in Section II.
[ ] 2. Patient was not informed of the consequences of the procedure but:
[ ] Was sterile prior to surgery. Explain __________________________________________________.
[ ] Was post menopause age ________________________.
[ ] Required a hysterectomy because of a life-threatening emergency in which prior consent was impossible. Explain Emergency _____________________________________________________
Distribution: One copy to patient; one copy retained by facility; one copy retained by physician; one copy retained by anesthesiologist.
FOR REIMBURSEMENT EACH PROVIDER MUST SEND A COPY OF THIS FORM TO OHIO DEPARTMENT OF JOB & FAMILY SERVICES.
JFS 03199 (Rev. 10/2003)
HISTORY: Eff 1-8-79; 2-6-79; 12-3-82; 7-1-83; 5-19-86; 8-1-01; 8-17-01; 3-1-05
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
R.C. 119.032 review dates: 11/12/2004 and 03/01/2010