Family Planning Benefit Expansion for Special Populations Billing Manual

• Program Overview
• General Billing Information
• Member Eligibility
  • Emergency Medicaid Services (EMS) Benefit
    • Program Funding
  • Family Planning Limited (FAMPL) Benefit
    • Presumptive Eligibility
• Covered Services
  • Family Planning Services
    • Sterilization Services
    • Basic Fertility Services
    • Emergency Medicaid Services Emergency Claims
  • Family Planning-Related Services
  • Covered Services Summary
• Provider Enrollment and Participation
  • Provider Referrals
• Billing Guidance
  • Professional Claims
  • EMS COVID-19 Only Benefits and Family Planning Claims
  • Federally Qualified Health Center (FQHC) / Rural Health Center (RHC) Billing
  • Hospital Inpatient Billing
  • Pharmacy Billing
  • High-Cost Claim Suspension
• Timely Filing
• Family Planning Revisions Log

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Program Overview

Starting July 1, 2022, the Colorado Department of Health Care Policy & Financing (the Department) has expanded family planning and family planning-related health benefits available to individuals who otherwise would not have been eligible for Health First Colorado (Colorado's Medicaid program) coverage. This expansion is based on two (2) bills passed in the 2021 legislative session, SB21-009 and SB21-025, and it was expanded in 2023 due to SB23-189.

Family Planning Benefit Expansion includes:

1. Emergency Medicaid Services (EMS) also referred to as the "Emergency Medical and Reproductive Health Care Program"
   • People residing in Colorado who do not meet citizenship requirements but meet all other eligibility criteria for Health First Colorado are eligible for coverage of family planning services, family planning-related services and emergency services.
2. Family Planning Limited (FAMPL) Benefit Plan
   • People residing in Colorado with incomes between 133% to 260% Federal Poverty Limit (FPL) but meet all other eligibility criteria for Health First Colorado are eligible for coverage of family planning and family planning-related services.

Visit the Reproductive and Maternal Health Programs and Resources web page for more information on the family planning benefit expansion benefits. Contact HCPF_MaternalChildHealth@state.co.us with questions.

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General Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu.

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Member Eligibility

Eligible individuals must complete the Health First Colorado application (available online, by phone, by mail or in person). All members will receive a Health First Colorado ID number and card. Providers can check a member’s eligibility through the standard member eligibility verification process. Refer to the Verify Member Eligibility and Co-Pay Quick Guide for more information on member eligibility.

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Emergency Medicaid Services (EMS) Benefit Plan

Emergency Medicaid Services (EMS) benefit plan now covers family planning, family planning-related and emergency services for individuals without documentation. EMS is also referred to as the “Emergency Medical and Reproductive Health Program.”

Eligibility requirements for the Emergency Medicaid Services (EMS) benefit include individuals who:

• Would be eligible for Health First Colorado coverage but do not meet citizenship requirements
• Meet the household income requirement for Medicaid coverage

There are no age or gender restrictions for coverage.

Effective July 1, 2023, EMS covers family planning-related services provided on or after this date. Due to the 2021 legislation of the EMS benefit, family planning-related services provided prior to July 1, 2023, will not be covered under the EMS benefit.

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Program Funding

This program is supported by state funds only, which creates a fixed annual budget, with limited funds allocated 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.

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Family Planning Limited (FAMPL) Benefit Plan

The Family Planning Limited (FAMPL) benefit plan covers family planning and family planning-related services for eligible individuals with an income above the Medicaid requirement. 

Eligibility requirements for the FAMPL benefit include individuals who:

• Have an income between 133%-260% FPL
• Would be eligible for Health First Colorado if they met the income requirement
• Are not pregnant OR are presumptively eligible for the benefit

There are no age or gender restrictions for coverage.

Members eligible for the FAMPL benefit plan are not eligible for other Medicaid services, but they may qualify for other programs, such as the COVID-19 only benefit (EMS=C), Specified Low-Income Medicare Beneficiary (SLMB) Program, and/or the Qualified Medicare Beneficiary (QMB) Program.

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Presumptive Eligibility

Individuals in the Family Planning Limited Benefit (FAMPL) program are eligible for Presumptive Eligibility to ensure immediate access to benefits. Presumptive Eligibility is a self-declaration of income, assets and status in order to promptly receive medical assistance services prior to verification. Presumptive Eligibility FAMPL members have the “PF” Program Aid Code and receive a Presumptive Eligibility 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. 

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Covered Services

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 include:

• All FDA-approved contraceptive methods and associated services, including up to a 12-month supply of the contraceptive
• Follow-up visits to evaluate or manage outcomes associated with contraceptive methods
• Pregnancy tests
• Sterilization services
• Basic fertility services
  • Counseling services focused on preventing, delaying or planning a pregnancy

Family planning services should be provided by Health First Colorado enrolled licensed practitioners providing services within the scope of their practice. Claims should have the appropriate CPT/HCPCS codes that are designated as family planning services with an FP modifier at the detail level on the claim. The diagnosis code on the claim should indicate that the intent of the visit was for “family planning services.” Health First Colorado members, including members in the EMS and FAMPL benefit plans, are not required to pay a copay for family planning services. Additional billing guidance is provided below.

Visit the Family Planning Services web page to learn more about services offered by Health First Colorado.

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Sterilization Services

Sterilization services are any medical bilateral procedure where the sole intent of the service is to render an individual permanently incapable of reproducing. Services require informed consent, which includes a 30-day wait period prior to the procedure and an accurately completed Consent to Sterilization - MED 178 attached to the claim. Exceptions to the 30-day wait period are made in cases of emergency abdominal surgery or premature delivery. The Sterilization Consent form is located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu and includes information that meets the requirements of State and Federal regulations. Refer to the Obstetrical Care Billing Manual for more information on sterilization services and requirements.

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Basic Fertility Services

Providers may provide services that help members plan for a pregnancy when this effort is identified as the family planning goal and service. 

This includes:

• Counseling regarding the reproductive system and fertility awareness (e.g., helping individuals predict when ovulation will occur)
• Initial evaluations of a member's ability to achieve a healthy term pregnancy (e.g., ultrasound to determine any anatomical barrier or sperm analysis) that would occur in a family planning setting

Services to treat identified fertility concerns are not covered under Health First Colorado. Providers should make appropriate referrals to specialist care if infertility continues. 

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Emergency Medicaid Services (EMS) Emergency Claims

Emergency services, including labor and delivery services, should be billed appropriately as an emergency based on EMS billing guidance. Visit the Health First Colorado’s Emergency Services Program web page for more information on the emergency services covered under the EMS benefit plan.

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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, or diagnosed, during a routine or periodic family planning visit. A follow-up encounter for STD/STI treatment and 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 or disorder is identified, or diagnosed, during a routine or periodic family planning visit. A follow-up encounter for treatment or drugs may be covered.
• Related evaluations or preventative services, such as tobacco cessation services or depression screenings.

Family planning-related services should be provided by Health First Colorado enrolled licensed practitioners providing services within the scope of their practice. Claims should have the appropriate CPT/HCPCS codes that are designated as family planning services with the FP+32 modifiers at the detail level on the claim. Health First Colorado members, including members in the FAMPL and EMS benefits programs, are not required to pay a co-pay for family planning-related services.

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Covered Services Summary

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Provider Enrollment and Participation

Providers must be enrolled with Health First Colorado to submit claims and be reimbursed for providing services to a Health First Colorado member.

Visit the Provider Enrollment web page if interested in becoming a Health First Colorado provider.

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Provider Referrals

An individual has free choice of an enrolled family planning provider 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.

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Billing Guidance

Professional Claims

The following modifiers are used to identify family planning and family planning-related services without a specified procedure code list.

Services that are not family planning and/or family planning-related should not have the FP and/or FP+32 modifiers. These are limited benefit plans and do not include other general Medicaid services. 

Claims under the EMS and FAMPL benefits plans are manually monitored, and the Department will contact providers regarding incorrectly submitted claims. 

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EMS COVID-19 Only Benefits and Family Planning Claims

The “EMS COVID-19 Only” benefit covers COVID-related testing, treatments and vaccines for individuals without insurance. This update impacts all claim types with dates of service on or after March 11, 2021.

If COVID-19 services are provided at the family planning visit for the FAMPL benefit plan, providers should submit the claim(s) as follows:

• For professional claims, providers can submit one (1) claim with the family planning services and COVID-19 services.
• For institutional claims, providers should submit two (2) claims--one for the family planning services and one for the COVID-19 services--due to the reimbursement bundling methods.

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Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs)

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) will be reimbursed at the standard encounter rate and are instructed to follow common billing practices when submitting a claim for members on the Family Planning Limited and EMS benefit plans. Family planning and family planning-related services should have the appropriate modifiers (FP or FP+32) at the line-level of the claim. Services provided at the visit that are not covered under the benefit plans should be added to the cost report.

Refer to the FQHCs and RHCs Billing Manual for more information. Contact HCPF_MaternalChildHealth@state.co.us with concerns regarding denied claims or incorrect information.

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Hospital Inpatient Billing

For hospital inpatient billing, the FP and FP+32 modifiers cannot be added to the detail level of the claim. For inpatient services, such as sterilization or Immediate Postpartum Long-Acting Reversible Contraception (IPP-LARC) device insertion, 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.

Refer to the February 2020 Provider Bulletin for further IPP-LARC billing instructions.

Refer to the Immediate Post-Partum Long-Acting Reversible Contraceptives (IPP-LARCs) information under the Separate Procedures section of the Obstetrical Care Billing Manual.

Provider feedback is appreciated. Contact HCPF_MaternalChildHealth@state.co.us with requests to add codes to this list.

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Pharmacy Billing

Pharmacy benefits include family planning and family planning-related services for members in the EMS and FAMPL benefits plans. Pharmaceuticals under these benefit plans have $0 copay.

Effective November 1, 2022, the Department implemented a code list of covered family planning-related drugs that do not require prior authorization. If the medication is not on the code list, the provider will have to submit a Prior Authorization Request (PAR) for FAMPL or EMS claims. Refer to Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criteria for more information regarding pharmaceutical prior authorization. 

Refer to the Pharmacy Billing Manual located on the Billing Manuals web page under the Pharmacy drop-down for pharmacy billing information regarding changes to family planning and family planning-related benefits.

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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 submitted claims 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 (3) 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 a family planning service covered by the EMS benefit and the inpatient claim exceeds $2500 and the outpatient claim line exceeds $2000.

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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Family Planning Revisions Log

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