Subsection 144-101-II-30.04 - COVERED SERVICESA covered service is a service for which payment to a provider is permitted under this section of the MaineCare Benefits Manual.The types of Family Planning Agency services are as described in sub-sections 30.04-1 through 30.04-8.
30.04-1Initial Patient VisitAn initial patient visit refers to an annual visit furnished no more frequently than once every 11 months, approximately 1 hour in length, which visit must include:
A. Pre-examination counseling and instruction concerning family planning methods, sexually transmitted diseases, immunizations, and reproductive health, all of which will normally take 15 minutes of the visit. B. Obtaining a medical and social history.C. Pre-exam preparation, including: blood pressure, height, weight, hemoglobin/hematocrit as indicated.D. Physical examination of the reproductive organs which may include a Pap smear and breast exam for women, and, when indicated, a screening for gonorrhea, chlamydia, condlyloma, HSV, hepatitis B, HIV, and vaginal infections. If a Pap smear has been furnished within the preceding 12 months by another provider and the results of a negative smear are documented in the member's chart, the repetition of this exam will not be reimbursed. If a Pap smear furnished within the preceding 12 months has shown a positive finding and if those results have been documented in the member's chart, then MaineCare reimbursement for an initial patient visit shall be made. This visit may also include:
E. Prescription and dispensation of the contraceptive method chosen by the member.F. Provision of related contraceptive supplies.G. Consultation and referral, when appropriate. Record entries relative to the patient visit, both initial and annual, must be made by qualified family planning agency staff (MD, P.A., Nurse Practitioner, Certified Nurse Midwife, or family planning specialists).A family planning specialist may make record entries relative to counseling, instruction, and other support services provided under the supervision of one of practitioners listed above.
30.04-2Established Patient VisitA. An established patient visit is a follow-up visit that involves one or more of the following: 1. Monitoring the contraceptive method, checking and regulating the performance of contraceptives,3. Gestation exams to confirm pregnancy or to estimate dates of delivery,4. Breast and/or pelvic exams, where medically indicated,5. Infection testing, treatment, or check,6. Sexually transmitted disease testing, diagnosis, treatment, immunizations, or check,7. Blood testing for HIV and Hepatitis.B. An established patient visit must include the review and updating of the member's medical and social history. When the need is indicated, it shall also include the following:1. Counseling and instruction concerning problems associated with the revisit of approximately 15 minutes in length.2. Pre-exam preparation, which shall include taking of blood pressure, hemoglobin/hematocrit as indicated, height, and weight.3. Examination of the reproductive organs, which may include a Pap smear and breast exam for women, and, when indicated, screening for sexually transmitted diseases.4. Counseling and referral.C. A follow-up visit for the purpose of obtaining a refill or re-supply of contraceptives must include one or more of the services identified in 30.04-3(A). Record entries relative to follow-up visits must be made by qualified family planning agency staff, MD, P.A., Nurse Practitioner, Certified Nurse Midwife, or family planning specialists.
30.04-3Early Prenatal Services VisitAn early prenatal services visit is a visit which provides a recipient with a start in her prenatal care and counseling on the importance of continued, regular prenatal care. The continuation of prenatal care is established during this visit with a confirmed appointment to a prenatal provider. A prenatal provider is a professional providing services within the scope of practice of his or her profession as defined by State Law and licensed under State Law to practice medicine or osteopathy, or a professional who is currently licensed to practice in the State as a nurse practitioner or nurse-midwife in collaboration with a licensed physician.
The family planning agency will maintain a list of at least three prenatal providers who will accept members for continued care from which the member may choose. Family planning agencies may only provide early prenatal visits under a written physician's protocol. The protocol must include a list of conditions and/or symptoms requiring referral to the prenatal provider within twenty-four hours. The prenatal provider must agree to accept results of any laboratory tests completed at the early prenatal visit, and the family planning agency must transfer copies of member records to the prenatal provider. To ensure continuity of care, the family planning agency will use the medical chart of the prenatal provider receiving the referral.
30.04-4Counseling TimeCounseling time refers to additional time needed to complete an initial patient visit or an established patient visit, or to conduct a separate visit for consulting and/or instructing only. Counseling time is to be billed in 15 minute increments and shall be provided by staff described in 30.06-1. Counseling time is available for the following:
A. Pre-sterilization counseling, which includes instruction about procedures available, explanation of the concept of informed consent and completion of the Department's consent form, appropriate referrals, and follow-up. B. Problem pregnancy counseling, which involves assisting the pregnant member in reaching a decision concerning the outcome she desires for the pregnancy and in obtaining the care needed to attain that outcome.C. Sexuality counseling, which is aimed at resolving conflicts or problems that interfere with the effective use of contraceptive methods.D. Sexually transmitted disease counseling, which includes informing the member of positive test or exam results, referring the member for additional testing and/or treatment, immunizations, and tracking the member's contacts, if appropriate.E. Nutritional counseling, which is aimed at instruction and counseling for members who have or are at risk of having diet-related medical conditions.F. Pregnancy testing counseling, which is aimed at instruction, counseling, and/or referral for members with a medical necessity for additional counseling. This service may be provided and billed on the same day as the pregnancy testing visit.G. HIV counseling, which is aimed at informing members of HIV test results, risk reduction counseling, referral and additional testing.30.04-5Off-Site Delivery of Services Off-site delivery of services is provided to members at family planning sites away from the main office when it is documented that no other means is available to obtain family planning services.30.04-6Pregnancy TestingA pregnancy testing visit includes appropriate documentation of the member's medical and/or social history, the pregnancy test, counseling, and referral to appropriate medical and/or social services.
30.04-7Special Diagnostic ProceduresSpecial diagnostic procedures are services provided to the member and approved by the Office of MaineCare Services. The approval will be based on the submission of a specific training protocol and written certification by the Medical Director of the Family Planning Agency. Only those special diagnostic procedures specified in Chapter III of this Section will be considered a covered service.
30.04-8ImmunizationsProvision of immunization services for sexually transmitted diseases including but not limited to Hepatitis B, where medically indicated. Immunization information must be shared with the MaineCare member's primary care provider (PCP) and entered into the immunization information system (IMMPACT) when available.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-30, subsec. 144-101-II-30.04