5101:3-21-02.3 Limited family planning benefit.

(A) The following definitions apply for the purposes of this limited medicaid benefit:

(1) "Pregnancy prevention/contraceptive management services" or "family planning services" are defined in rule 5101:3-21-02 of the Administrative Code.

(2) "Family planning-related services" are medically necessary services identified during a routine or periodic family planning visit that satisfy two criteria:

(a) They belong to one of four specific types:

(i) Diagnosis of sexually-transmitted diseases or infections (STIs);

(ii) Treatment of STIs other than human immunodeficiency virus (HIV) and hepatitis;

(iii) Mammography when indicated by a breast examination; or

(iv) Vaccinations against human papillomavirus (HPV) or hepatitis B provided in accordance with rule 5101:3-4-12 of the Administrative Code; and

(b) They are provided as part of a family planning visit or within sixty days of the family planning visit where their need was determined.

(B) Individuals who meet the eligibility criteria in rule 5101:1-41-40 of the Administrative Code have a limited medicaid benefit that only includes the following:

(1) Family planning and family planning-related services listed in the appendix to this rule;

(2) Hospital services covered in Chapter 5101:3-2 of the Administrative Code when provided as a family planning-related service as defined in this rule; and

(3) Medicaid-covered, FDA-approved drugs covered in Chapter 5101:3-9 of the Administrative Code when provided as a family planning-related service as defined in this rule.

(C) When submitting claims for services available under the limited family planning benefit, providers must include the information specified in rule 5101:3-21-02 of the Administrative Code. All claims, including pharmacy claims, for family planning and family planning-related services must be submitted with a family planning diagnosis code in the V25 series.

Click to view Appendix

Effective: 03/28/2013
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 01/01/2012, 12/30/2012 (Emer)