Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Members have the right to access family planning services without prior authorization from any qualified participating or non-participating family planning provider in or out of Health Net's service area. A qualified family planning provider includes a member's primary care physician (PCP) and other participating or non-participating providers, including obstetricians/gynecologists (OB/GYNs), nurse midwives, nurse practitioners (NPs), physician assistants (PAs), federally qualified health centers (FQHCs), and county family planning providers.
Capitated participating physician groups (PPGs) are responsible for payment of claims to all qualified family planning providers for appropriate billable services covered by the Department of Health Care Services (DHCS) Medi-Cal fee-for-service (FFS) program, including office visits, laboratory tests, and Medi-Cal approved contraceptive medications, devices and supplies. Refer any problems involving claims payment responsibility to a Health Net provider network management representative.
Problem Resolution
Any conflicts concerning provision of family planning services, excluding member or provider grievances or appeals, should be referred to Health Net's public programs administrators for resolution. During any problem periods, a Health Net care manager and the PCP or specialty provider continues to coordinate the member's care.
Provider Responsibilities
Providers may not restrict a member's access to family planning services or subject a member to any prior authorization process for them. Providers who do not comply are subject to administrative review or disciplinary action.
The family planning provider must obtain informed consent for sterilization. A signed Consent Form (PM-330 (PDF)) must be included with all claims for payment for sterilization.
The following information applies only to Medi-Cal PPGs and physicians.
The following family planning services are covered for all members of childbearing age:
- Health education and counseling necessary to make informed choices and understand contraceptive methods.
- Limited history and physical examination.
- Laboratory tests, if medically indicated, to assist with decision-making for contraceptive methods (except cervical cancer screening, such as Pap test, provided by a nonparticipating provider where Health Net has previously covered a cervical cancer screening performed by a participating provider in accordance with current U.S. Preventive Services Task Force (USPSTF) guidelines).
- Diagnosis and treatment of sexually transmitted infections (STIs) (one visit per episode when provided by nonparticipating providers).
- Screening, testing and counseling of individuals at risk for HIV infection.
- Most methods of sterilization (the member must be at least age 21 at the time consent is obtained), including:
- Tubal ligation.
- Vasectomy.
- Same methods of birth control as covered by the Department of Health Care Services (DHCS) for the Medi-Cal fee-for-service (FFS) program, devices and supplies (including Depo-Provera® and Lunelle™). Members may receive up to a 12-month supply dispensed at one time for U.S. Food and Drug Administration (FDA)-approved, self-administered hormonal contraceptives, such as 13 vaginal rings, 52 patches and 18 cycles of oral contraceptives.
- Oral contraceptives are covered when dispensed from an onsite clinic and billed by any qualified provider. A qualified provider is a provider who is licensed to furnish family planning services within their scope of practice, is an enrolled Medi-Cal provider, and is willing to furnish family planning services to a Medi-Cal enrollee as specified in Title 22, California Code of Regulations, Section 51200. A physician, physician assistant (under the supervision of a physician), certified nurse midwife, nurse practitioner, and pharmacist are authorized to dispense medications. When furnished by a pharmacist self-administered hormonal contraceptives must be dispensed in accordance with a protocol approved by the California State Board of Pharmacy and the Medical Board of California. Pursuant to the California Business and Professions Code (B&P Code), Section 2725.2, if contraceptives are dispensed by a registered nurse (RN), the RN must have completed required training pursuant to B&P Code Section 2725.2(b), and the contraceptives must be billed with evaluation and management (E&M) procedure codes 99201, 99211 or 99212 with modifier TD (used for behavioral health RN) as directed in the DHCS Medi-Cal Provider Manual.
- Office-administered follow-up treatment of complications associated with contraceptive methods issued by a family planning provider (limited to two outpatient visits without prior authorization, when provided by a nonparticipating provider).
- Outpatient office visits to manage minor issues associated with hormonal methods of birth control, not limited to two visits; prior authorization is not required.
- Pregnancy testing and full-options counseling when performed by trained staff under the supervision of a licensed physician.
Health Net encourages the primary care physician (PCP) to coordinate care with non-participating providers to avoid duplication of services. If the PCP previously provided the service the non-participating provider is now providing, the non-participating provider is not paid (unless they have documented attempts to contact the member's PCP for medical information).
When a member requests that medical records be forwarded to a non-participating provider, it is the PCP's responsibility to comply. The PCP must obtain a completed signed consent form from the member for records to be transferred to the non-participating provider.
If the member needs medically necessary follow-up care, the non-participating provider must obtain a signed consent from the member to notify the member's PCP. Health Net's Health Services staff are available to assist non-participating providers if any concerns about timely provision of services and referrals arise.
Health Net provides new members the following information on family planning services through the Evidence of Coverage (EOC):
- The member's option to receive family planning services from any qualified participating provider (in- or out-of-network), without referral or prior authorization of coverage
- A complete list of the services offered and descriptions of limitations on the family planning services members may seek from non-participating providers
- The member's right to timely services
- Notification that members must provide informed consent for sterilization
- That confidentiality of medical information and personal data of all members is maintained through strict adherence to applicable state and federal requirements
- The member's right to confidentiality when receiving socially sensitive services, including the availability of services for minors without parental consent
- The positive effect of coordinated care on health outcomes