- Program Overview
- Billing Information
- Member Eligibility
- Covered Services
- Provider Enrollment and Participation
- Billing Guidance
- Timely Filing
- Family Planning Revisions Log
Starting July 1, 2022, the Colorado Department of Health Care Policy and Financing (the Department) has expanded the reproductive health benefits available to individuals who would not have otherwise been eligible for Health First Colorado services. This expanded coverage addresses barriers to our members accessing essential health care services that help all members and their families to thrive.
The new covered populations are:
- People residing in Colorado who do not meet citizenship requirements but meet all other eligibility criteria for Health First Colorado are now eligible for family planning services; and
- People residing in Colorado with incomes over 133% but under 260% FPL are now eligible for family planning and family planning related services.
The above benefit plans are delivered without co-pays to enrolled members for eligible services, and enrolled members may immediately receive a 12-month prescription and supply of contraception from their provider.
Email feedback regarding this billing manual to hcpf_MaternalChildHealth@state.co.us.
More information on the family planning benefit expansion legislative programs can be found on the Maternal, Child and Reproductive Health web page.
General Billing Information
Refer to the General Provider Information manual for general billing information.
For both reproductive health expansion populations, eligible individuals must complete the Health First Colorado application (available online, by phone, by mail or in person). Providers will also be able to check a member’s eligibility category through the standard member eligibility verification process.
Eligibility for People without Documentation
SB 21-009 created a family planning benefit program for individuals without documentation. Eligibility requirements for this benefit include individuals who:
- Would be eligible for Health First Colorado coverage but are not a citizen of the United States
- Are not pregnant
Eligible individuals receive coverage for family planning services only; family planning related services are not covered for these members. Members in this eligibility category are not required to pay a co-pay for covered family planning services.
This program is supported by state funds only, which creates a fixed annual budget, so there are limited funds allocated to this benefit each year. If funds are depleted by the time a claim is submitted, payment may be delayed until the next fiscal year (July 1st). The Department will provide a notice to affected providers if this occurs.
Expanded Income Eligibility
SB 21-025 created an expanded income category of members eligible for family planning and family-planning related benefits. Eligibility requirements for this benefit include individuals who:
- Have an income between the 134%-260% FPL
- Would be eligible for Health First Colorado coverage if they had an income below the 133% FPL OR are presumptively eligible for the benefit
- Are not pregnant
Members in this eligibility category are not required to pay a co-pay for covered family planning and family planning related benefits.
Individuals in the expanded income range are eligible for Presumptive Eligibility (PE) to ensure immediate access to benefits. PE is defined as the member’s self-declaration of income, assets, and status in order to promptly receive medical assistance services prior to the verification of income, assets, and status. PE members receive a PE card that identifies them as temporarily eligible for covered Family Planning and Family Planning Related services until Health First Colorado can determine their eligibility for full coverage. If a member has a PE card for these services, they are available for all the appropriate covered services discussed below.
Family Planning Services
Family planning benefits include essential medically necessary services where the intent of the service is to delay, prevent or plan for a pregnancy. Family planning services let members choose if, or when, to become pregnant or to become a parent. Family planning services include:
- All FDA-approved contraceptive methods and associated services, including up to a 12-month supply of the contraceptive
- Health care and counseling services focused on preventing, delaying or planning a pregnancy
- Follow-up visits to evaluate or manage outcomes associated with contraceptive methods
- Sterilization services
- Basic fertility services
Covered family planning services should be provided in a family planning setting and designated with a FP modifier at the detail level on the claim. Health First Colorado members and members in the expanded income and citizenship status categories are not required to pay a co-pay for family planning services.
Learn more about Family Planning Services offered by Health First Colorado.
Family Planning-Related Services
Family planning-related services are essential medically necessary services provided in a family planning setting as part of or as follow-up to a family planning visit. Such services are provided because they were identified, or diagnosed, during a family planning visit. Family planning-related services could include:
- Drugs for the treatment of sexually transmitted diseases (STD) or sexually transmitted infections (STI) when the STD/STI is identified/ diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for STD/STI treatment/drugs may be covered. In addition, subsequent follow-up visits to rescreen for STIs/STDs based on the Centers for Disease Control and Prevention guidelines may be covered.
- Services provided at an annual family planning visit regardless of gender. Additional services provided at an annual family planning visit may include a comprehensive patient history, physical, laboratory tests, cervical cancer screening and prevention and contraceptive counseling.
- Drugs for the treatment of lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection/disorder is identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/ drugs may be covered.
- Related evaluations or preventative services, such as tobacco cessation services.
Covered family planning related services should be provided in a family planning setting during a family planning visit and designated with a FP+32 modifier at the detail level on the claim. Health First Colorado members and members in the expanded income category are not required to pay a co-pay for family planning related services.
|Family Planning Services||Family Planning Related Services|
|Covered Services||Family planning services are services provided in a family planning setting with the intent to help members choose if, or when, to become pregnant or to become a parent.
|Family planning-related services are associated medically necessary services provided in a family planning setting as part of or as follow-up to a family planning visit.
|Benefit Expansion Eligibility||
Provider Enrollment and Participation
Providers must be enrolled with Health First Colorado in order to submit claims and be reimbursed for providing services to a Health First Colorado member enrolled in one of these benefit programs.
If interested in becoming a Health First Colorado provider, please refer to the Provider Services Enrollment section of the Department's website.
An individual has free choice of a family planning provider enrolled in Health First Colorado and cannot be required to obtain a referral prior to choosing a provider for family planning services. Members covered by managed care organizations can select any qualified family planning provider from in network or out-of-network without referral.
The following modifiers are used to identify family planning and family planning-related services without a specified procedure code list.
|FP||Family Planning Service (FP)|
|FP + 32||Family Planning-Related Service (FP-R)|
Note: Undocumented members are eligible for family planning services ONLY; claims with the FP+32 modifier for family planning-related services will deny for this specific eligibility population.
Hospital Inpatient Billing
In the case of an inpatient procedure (such as a sterilization or Immediate Postpartum Long-Acting Reversible Contraception [IPP-LARC] device insertion) in which modifiers are not specifically identified on a submitted claim, providers must use the ICD-10 diagnosis and surgical procedural (PSC) codes below to identify the family planning service.
Note: Inpatient claims for these populations will only pay if the claim is limited to these approved services. If any lines on the claim have a service that would not be covered (listed below), then the whole claim will deny.
The Department will modify coding instructions to clarify billing. We appreciate provider feedback: Please email hcpf_MaternalChildHealth@state.co.us with requests to add codes to this list.
|Service||Procedure Codes||Diagnosis Code
|LARC - IUD||
|LARC - Implant||
For outpatient pharmacy billing related to family planning and family planning related services, please see the Pharmacy Billing Manual under Family Planning and Family Planning Related Services for billing information.
High-Cost Claim Suspension
For all of these categories of service (professional, inpatient and pharmacy claims), the Department monitors claims submitted under these benefit programs. If claims are submitted that appear to be inconsistent with the benefit, the provider may be contacted to gather more information. Claims over a certain amount will be suspended until the Department can review the claim. Once the claim is reviewed to ensure appropriate utilization, it will be paid. There may be a delay in payment of up to three weeks.
- For claims that price at the detail level:
- The Department will suspend high-cost Family Planning claims when the professional, professional crossover, inpatient, or inpatient crossover claim line dollar amount exceeds $1500, when the claim/claim line is not an emergency and is determined to be a family planning service.
- For claims that price at the header level:
- The Department will suspend high-cost outpatient, inpatient and crossover claims when the claim is not determined to be an emergency and is covered by the FP EMS benefit and the IP claim exceeds $2500 and the OP claim line exceeds $2000
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.
Family Planning Revision Log
|Revision Date||Addition/Changes||Made by|
|6/21/2022||Creation of Family Planning manual||HCPF|