‘Be Smart’ Family Planning Clarification on Sterilization and Eligibility

Background on Family Planning Medicaid

The provision of family planning services and family planning-related services has been the sole purpose of the “Be Smart” Family Planning Medicaid program since it started in October 2005, and continued with the CMS approval of the State Plan Amendment in 2014.

“Be Smart” Family Planning Medicaid, listed as MAFDN eligibility category in NCTracks, provides limited coverage to eligible beneficiaries. Family Planning Medicaid serves eligible beneficiaries, regardless of age or gender, but covers family planning and family planning related services only, as described in Clinical Policy 1E-7, Family Planning Services. Therefore, beneficiaries with MAFDN eligibility are not eligible for any other Medicaid program or categories of service.

Be Smart and Sterilization

Providers have been seeking clarification from N.C. Medicaid about sterilization and eligibility under the “Be Smart” program. The Centers for Medicare and Medicaid Services (CMS) notified N.C. Medicaid that it is not acceptable to ask questions related to a beneficiary’s sterilization status during the Medicaid application process. Therefore, some beneficiaries will be approved for Family Planning Medicaid who have no need for family planning services.

Though Department of Social Services (DSS) staff cannot ask beneficiaries questions about sterilization status during the application process, providers must do so before rendering services. It is imperative that providers determine if Medicaid beneficiaries need family planning services prior to providing any other services under the program (e.g., annual or physical exams). Providers shall not bill Medicaid for any service rendered under Family Planning Medicaid for a beneficiary who does not have family planning needs. Claims may be subject to audit to ensure proper billing.

Additional information about the “Be Smart” program and eligibility for services is found in the next section.

Guidance for Providers of ‘Be Smart’ Services

General Medicaid eligibility and Family Planning Medicaid (“Be Smart”) are separate and distinct. Family Planning Medicaid (“Be Smart”) encompasses the need for family planning services (contraceptive or birth control services), because the beneficiary wants to prevent or delay having children. However, there is no indication on the Medicaid identification card that the beneficiary is eligible for family planning services only.

The following guidance will prevent providers from rendering family planning services to beneficiaries for which the provider cannot be reimbursed.

1. Providers shall verify each beneficiary’s type of coverage prior to each visit. Though DSS workers cannot ask beneficiaries questions about their ability to bear children during the application process, providers must do so before rendering services. (Beneficiaries do receive a letter with their card that informs them of the limitations of their coverage.)
2. Eligible beneficiaries are entitled to receive one annual exam each year and six inter-periodic visits per 365 days, thereafter. All services covered under this program must be related to family planning or family planning-related reasons. Providers shall confirm that the beneficiary is seeking family planning services.
3. Providers shall screen and inform beneficiaries that the Family Planning Medicaid program is strictly for family planning services, as indicated in Clinical Policy 1E-7, Family Planning Services. Policy states that the beneficiary is no longer eligible to receive services under the program once they have been determined to be permanently sterilized.
4. A beneficiary who is sterilized under this program can receive all related follow up to the surgery, per policy. Once follow up is complete, they should be informed that they are no longer eligible for services under Family Planning Medicaid.
5. If it is discovered during screening that the beneficiary has no need for Family Planning Services (permanently sterilized, post-menopausal, sterile, post-hysterectomy, not capable of having children, etc.), Medicaid shall not be billed for the service. Providers should inform the beneficiary that the visit can continue but that the beneficiary would be responsible for the cost of the services provided on that day. The beneficiary should be informed of the cost of the visit and be told that they can choose to leave at that point and not be charged for the appointment.
6. Comprehensive screening prior to exam should prevent the discovery – during the exam – that the beneficiary does not need family planning services. However, if the discovery does occur during the exam, the provider cannot bill the beneficiary or Medicaid. The provider should inform the beneficiary that future visits will not be covered under Family Planning Medicaid because they are not eligible for family planning services. The beneficiary will be responsible for payment of any future services. If the provider is seeking payment from the beneficiary, the provider shall inform the beneficiary prior to rendering the service (see 10A NCAC 22J. 0106). The provider shall not bill Medicaid for family planning visits, when the beneficiary has no need for family planning services.
7. Available options for the beneficiary may include:

• The beneficiary may contact the Department of Social Services to determine whether they are eligible for another Medicaid program.
• The beneficiary can request services for which they would be asked for payment, in whatever manner the provider usually seeks private payment (sliding scale, payment plan, etc.).