Maryland Medical Assistance

 

Program Overview

Who is eligible for the expanded Family Planning Program?

The Maryland Medical Assistance Family Planning Program is for any woman who is at or below 200% Federal Poverty Level (FPL), under 51 years old, and who is a citizen or qualified alien residing in Maryland.  A woman may qualify even if she has other third party insurance (not including Medical Assistance or Medicare).  Women who are pregnant or have obtained permanent sterilization are not eligible for the Family Planning Program.  The Family Planning Program does not cover services for men. 

 

What services are covered under the Family Planning Program? 

The Family Planning Program is a Medical Assistance fee-for-service program that covers family planning services only.  Services covered during clinic or doctor visits for birth control include:

• Pelvic exams;
• Screening tests, such as pap smears and sexually transmitted infections, as part of a family planning visit;
• Advice about birth control methods;
• Birth control pills and devices;
• Treatment for family planning-related conditions detected in the context of a family planning visit; and
• Permanent sterilizations for women age 21 or older (tubal ligations and Essure).

A list of the current CPT codes billable under the Family Planning Program can be seen at the end of this FAQ.   

 

Which family planning-related services are NOT covered by the Family Planning Program? 

The Family Planning Program does not cover abortion, infertility, or sterilization reversals.  The Family Planning Program does not cover colposcopy, mammography, or ultrasounds.

 

How long is a woman eligible for the Family Planning Program after she receives a sterilization procedure utilizing the Family Planning Program?

Women who have obtained a sterilization procedure should notify the Family Planning eligibility unit.  Their eligibility will end at the end of the month in which the sterilization procedure was performed.  An exception to this is for women who have had the Essure procedure – their eligibility will not end until they have received the confirmatory three month post-procedure hysterosalpingogram.  

 

How is the expanded Family Planning Program related to the previous postpartum Family Planning Waiver Program? 

This Family Planning Program is an expansion of the previous postpartum Family Planning Program.  Prior to January 1, 2012, women who had been enrolled in Medical Assistance for pregnancy coverage and were   Women were not eligible if they had third party insurance.  

Under the program expansion, postpartum women at or below 200% FPL will continue to be automatically enrolled in the Family Planning Program for 12 months. They will then need to recertify eligibility for the program every 12 months.  There is no longer a time limit for the program, which means that participants can continue to reapply yearly.  

 

How is the Family Planning Program related to the Medical Assistance for Families program? 

The Family Planning Program is a separate fee-for-service program with higher income limits than the Medical Assistance for Families (MA4F) programs.  MA4F provides healthcare for both men and women with incomes less than 116% FPL, including family planning services. In addition to family planning, MA4F covers primary care, pharmacy, mental health, substance abuse treatment, and ER facility charges. MA4F requires enrollment in a Managed Care Organization (MCO).  

Women with incomes less than 116% FPL who do not have children in the household should be encouraged to apply for Medical Assistance.  Women with dependents with income limits less than 116% FPL should apply for MA4F, along with their children. MA4F does provide sterilization benefits.   

All women with Medical Assistance have access to family planning benefits regardless of the specific program, including if she participates in an MCO.  Women may “self-refer” to their provider of choice for family planning services.  This means that women do not need prior authorization or approval from their Primary Care Provider to seek family planning services from any appropriate medical provider or clinic even if out-of-network or out-of-plan with the MCO. 

 

Application Process

How do women apply for the Family Planning Program?

Applications are available by calling toll free at 855-692-4993 or downloadable here.

English Application      

Spanish Application 

The applications should be mailed or faxed to:

Department of Health & Mental Hygiene

Family Planning Program

PO Box 296

Baltimore, MD 21298-9795

Fax #: 410-333-0134

Clinics and healthcare providers may distribute applications, actively assist women in completing their applications, and mail or fax applications for clients.  

 

What is the eligibility and enrollment process for the Family Planning Program? 

An applicant is required to fill out a short paper application, listing verifiable income and citizenship information. She may also be contacted for additional information as needed.  Applications will be processed within 45 days. If an applicant is determined to be eligible, coverage will begin on the first day of the month the application was received by the Department of Health and Mental Hygiene.  Providers will not be reimbursed for services provided while eligibility is pending if the applicant is subsequently found ineligible.   

It is important to always check the Eligibility Verification System (EVS) (online at https://encrypt.emdhealthchoice.org/emedicaid/ or by telephone at 1-866-710-1447) to see if a patient already has coverage under another Medical Assistance Program.  This will save time in the application process, allow the clinic or healthcare provider to bill immediately, and give women immediate access to contraceptive services.  It is unnecessary for women who are already enrolled in Medical Assistance to complete the Family Planning Application.  If an application is received from a woman already enrolled in a Medical Assistance Program, the application will be denied.  

 

Who is responsible for eligibility and enrollment for the Family Planning program?  

Eligibility will be determined centrally by Medical Assistance staff.  Clinics and healthcare providers may facilitate enrollment for clients by doing outreach in the community, making information and application materials available, and encouraging other agencies to do so.  They may actively assist clients by helping women fill out applications while they are waiting for services, mailing or faxing the application on the client’s behalf, etc.  Clinics and healthcare providers may also choose to allow a client to use their clinic address as a alternate contact “in care of” or name the family planning provider or clinic as her authorized representative so that nothing is mailed to her home, including her Family Planning Program card (purple and white card), which might compromise her confidentiality. 

 

Will eligible women have to enroll in an MCO? 

No.  Women who qualify for the Family Planning Program will not be enrolled in an MCO. The program reimburses providers on a fee-for-service basis.  

 

Adolescents and Confidentiality

Note: If an adolescent has an involved parent, and the family income is no more than 200% FPL, the parent may want to complete an application for the Maryland Children’s Health Program (MCHP) so the adolescent can get full Medical Assistance coverage, including family planning. MCHP counts the parent’s income in determining eligibility for the program.   

 

Will adolescents have to report their parents’ income for the Medical Assistance Family Planning Program?

No.  Adolescents may qualify for the Family Planning Program based on their own reported income.  The parents’ income is not considered.  

 

Will adolescents be allowed to apply without parental consent? 

Yes, adolescents can apply without parental consent.  

 

How is this related to the Minor Consent Law? 

Maryland Law allows minors to access family planning services without parental consent.  However, since the Medical Assistance Program requires that providers bill other insurers first – and other insurers send out Explanation of Benefit statements – it is best not to bill the Program when an adolescent has third party insurance and requests that the service be kept confidential.  

 

What happens if a woman does not report her third party insurance? 

The Medical Assistance Program uses both the information that a recipient reports on her application and other databases to determine if another insurer may be responsible for a claim. Providers need to check EVS for eligibility and information on third party insurance.  Because of the dynamic nature of insurance coverage, there can be a lag in adding and removing insurance information. Therefore, it cannot be assumed that a woman does not have third party insurance if does not come up on EVS.  If EVS gives you information on another insurer, you must bill that insurer prior to billing Medical Assistance.  In addition, if the client reports additional insurance, you should bill the other insurance prior to billing Medical Assistance regardless of whether that information is also available on EVS.  

If the third party insurance does not cover the claim, they will send a rejection letter to the provider. The provider can then submit a claim to Medical Assistance and must attach the rejection letter with the proper rejection code in Box 11 on the CMS 1500 claim form.  If the other insurance pays, you may not balance bill the recipient. 

 

Can adolescents have their card sent to another location?

Yes.  Clients may have information related the to family planning program sent to them at an alternate location, such as a friend’s house.  Additionally, clinics and healthcare providers may choose to allow a client to use their clinic address as a alternate contact “in care of” or name the family planning provider or clinic as her authorized representative so that nothing is mailed to her home, including her Family Planning Program card (purple and white card), regardless of age.  

 

What should I do if an adolescent or woman requests that the service be keep completely confidential?

If there is a confidentiality concern (for teens or victims of abuse/trafficking) and you know or suspect that a patient has other insurance, you should NOT bill Medical Assistance or the third party insurance.  Healthcare providers may provide family planning services and charge these patients per clinic protocol or refer a client to a Title X funded family planning clinic.  Title X Family Planning clinics have a long history of providing confidential family planning services and are located in every jurisdiction throughout the State.  Clients seeking family planning services in a Title X clinic will be billed based on their self-reported income.  Individuals at or below 100% FPL or under the age of 18 are provided services at no charge, while clients who are between 100% - 250% of FPL are provided services on a sliding fee scale.  Clients who have a self reported income greater than 250% of FPL are charged full fee.  A list of Title X clinics can be found under the “Family Planning Clinic Sites” on the Department of Health and Mental Hygiene, Center for Maternal and Child Health’s Family Planning and Reproductive Health website.

 

Reimbursement and Becoming a Medical Assistance Provider

How will providers be reimbursed for services?

All providers of family planning services, except Federally Qualified Health Centers, are paid according to the Medical Assistance Program Physician Fee Schedule.  The “2011 Physician Fee Schedule” can be found on the Medical Assistance Provider Information website:  http://mmcp.dhmh.maryland.gov/SitePages/Provider%20Information.aspx

Federally Qualified Health Centers will be paid according to current cost-based reimbursement rates. 

 

How do I become a Medical Assistance fee-for-service provider?

If you would like to become a Medical Assistance provider, fill out and submit the “Provider Agreement” and “Provider Application” located at:  https://encrypt.emdhealthchoice.org/emedicaid/ 

 

Who to Contact

• General Family Planning Program and enrollment information: 1-855-692-4993
• Billing questions: 1-410-767- 5503
• General Family Planning Program covered benefits and services: 1-410-767-6750
• Questions about becoming a Medical Assistance provider: 1-800-766-8692