Effective March 23, 2010, states may amend their Medicaid plans to cover family planning and related services for individuals who are not eligible for Medicaid under any other category, according to a CMS letter to state Medicaid directors. The eligible group may include individuals with incomes up to the state’s income limit for pregnant women under Medicaid and CHIP.
The benefits available to individuals in this group are limited to family planning services and related services. Related services include those that are usually provided with the family planning service, such as testing and treatment for sexually transmitted diseases or other conditions discovered during the family planning visit, or screenings and vaccination for cancer of the cervix. In states where family planning programs cover an annual physical examination for men, the physical may be covered as a related service. States will be reimbursed at the 90 percent rate for family planning services and at their ordinary rate for the related services. States may apply presumptive eligibility to this group as permitted by Soc. Sec. Act §1920C and must include this eligibility category when reviewing the eligibility of women who are losing their coverage as pregnant women. The state may use the same rules applicable to pregnant women, under which only the income of the applicant is counted even if he or she would ordinarily be considered part of a household or family or treating the individual as a household of two.
Coverage under a waiver
States that have family planning waiver programs under Soc. Sec. Act §1115 may change to the optional benefit. If they do, they must at least maintain the eligibility standards used in the waiver until the health insurance exchange required by the Patient Protection and Affordable Care Act (PPACA)(P. L. 111-148) is established. States that previously provided a family planning benefit under a waiver may treat as eligible individuals who would have been eligible under the demonstration if they had applied on or before January 1, 2007.
Amendment of the state plan to add this eligibility group and benefit will have no effect on the state’s eligibility for the increased federal financial participation for the new mandatory eligibility group on January 1, 2014.
CMS Letter to State Medicaid Directors, No. SMDL-10-013, July 2, 2010.For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
Visit our News Library to read more news stories.
