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Minnesota Department of Human Services Provider Manual
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Minnesota Family Planning Program (MFPP)

Revised: 08-22-2014

  • Overview
  • Eligible Providers
  • Dispensing by Protocol – Family Planning Registered Nurse
  • Presumptive Eligibility
  • MFPP Provider Certification
  • Referrals to Other Providers
  • Eligible Recipients
  • Confidentiality
  • Covered Services
  • Verify Eligibility
  • Pharmacy Services
  • Contraceptive Medications and Supplies
  • Lab Services
  • Secondary MFPP Services
  • Non-Covered Services
  • Billing
  • Lab Services
  • Legal References
  • Overview

    This section includes MHCP coverage and billing policy for the Minnesota Family Planning Program (MFPP) providers.

    MHCP offers MFPP as a separate set of Family Planning services. Provider, recipient, and service delivery requirements are not the same for MFPP and non-MFPP MHCP family planning services. Refer to the Reproductive Health/OB/GYN overview page for links to other related services.

    The Minnesota Family Planning Program (MFPP) provides family planning services and supplies for women and men ages 15 years to 50 years, (eligibility begins the first day of the month of the 15th birthday through the end of the month of the 50th birthday), who are not eligible for other MHCP programs, and meet certain income guidelines. The main goal of MFPP is to reduce the number of unintended births, thereby reducing costs to Minnesota’s publicly funded health care programs.

    Eligible Providers

    The following enrolled MHCP providers are eligible to provide services to MFPP recipients:

  • Ambulatory surgical centers
  • • Anesthesiologists and CRNAs
  • • Certified nurse midwives
  • • Clinical nurse specialists
  • • Community health clinics
  • • Family planning agencies
  • • Federally Qualified Health Centers (FQHCs)
  • • Indian Health Services (IHS/638 facilities)
  • • Laboratories
  • • Nurse practitioners
  • • Outpatient hospital departments
  • • Pharmacies
  • • Physician assistants
  • • Physician-directed clinics
  • • Physicians
  • • Public health clinics
  • • Rural health clinics (RHCs)
  • Dispensing by Protocol – Family Planning Registered Nurse

    A registered nurse (RN) in a family planning agency may dispense oral contraceptives prescribed by a licensed practitioner, according to a dispensing protocol established by the agency’s medical director or under the direction of a physician. RNs may not dispense oral contraception to a recipient who is less than twelve years of age. Follow state requirements for dispensing prescription drugs.

    Presumptive Eligibility (PE)

    Presumptive eligibility is a short-term period of eligibility determined at the point of service by a certified MFPP provider. At the time a presumptive eligibility determination is made, the certified MFPP provider gives the applicant a MFPP Short-Term Approval Notice, available online through the MN–ITS site. Other providers, including pharmacies and labs, must accept this form as proof of eligibility for the dates indicated.

    Before you determine PE you must verify eligibility on MN–ITS, IVR or X12 270/271. Recipients currently eligible for any Minnesota Health Care Program (MHCP) (including MinnesotaCare) are not eligible for PE. Give current MHCP recipients a denial notice, and forward the application to DHS for a formal denial.

    MFPP Provider Certification

    Certified MFPP providers are individuals and clinics providing primary family planning services that are certified by DHS to determine presumptive (short-term) eligibility for MFPP. Individual providers working in a certified clinic do not need separate certification when the clinic itself is certified.

    To become certified, a provider must have participated in a past MFPP training or complete the current online MFPP Training Guide (PDF), and submit the completed Certified Family Planning Provider Application Packet (DHS-4773) to:

    DHS-Provider Enrollment
    PO Box 64987
    St Paul MN 55164-0987

    Fax forms to: 651-431-7462

    For questions, please call the Provider Call Center at 651-431-2700 or 1-800-366-5411.

    Referrals to Other Providers

  • • Physicians, APRNs, clinics and family planning agencies serve as the primary care providers for recipient reproductive health services. Providers must make available to MFPP eligible recipients all services in the MFPP benefit package either directly or by referral
  • • Refer recipients only to enrolled MHCP providers, as recipients must not be billed
  • • Provide the primary diagnosis (V25. to V25.9 range), and any secondary diagnosis that applies and at least 2 of 3 identifiers (recipient first and last name, date of birth, SSN) sufficient for an outside lab or other providers to verify recipient MFPP eligibility using MN–ITS and bill for services performed.
  • When recipients require access to primary care services, direct them to the MHCP Provider Directory. Refer to the Minnesota Health Care Programs Application (DHS-3417), Required Proofs on page A, that lists verification requirements.

    Additional MFPP forms are also available from the MFPP office at 651-431-3480 or 1-888-702-9968.

    Eligible Recipients

    Certified MFPP providers will determine MFPP eligibility at the point of service. MFPP applicants may apply on their own behalf without the consent of anyone else. Eligibility for individuals under age 21 is not based on parental income. An eligible recipient for MFPP must:

  • • Be age 15 years to 50 years, (eligibility begins the first day of the month of the 15th birthday through the end of the month of the 50th birthday)
  • • Be a Minnesota resident
  • • Be a citizen or a qualified non-citizen
  • • Have income at or below 200% federal poverty guidelines (FPG) (individuals under age 21 are eligible based on their own income)
  • • Not pregnant
  • • Not institutionalized
  • Recipients have initial presumptive (short-term) eligibility for the month the MFPP provider determines them eligible, through the last day of the following month. MHCP will determine the recipient’s continued MFPP eligibility. If found eligible, the recipient has MFPP coverage for an additional twelve months. MFPP eligibility ends before the annual renewal if the recipient has one of the following occur:

  • • Is no longer a Minnesota resident
  • • Voluntarily terminates eligibility
  • • Become eligible for MA or MinnesotaCare
  • • Turns age 50 years (eligibility terminated at the end of the month of the 50th birthday)
  • • Becomes pregnant
  • • Becomes institutionalized
  • Confidentiality

    All partner agencies of the Minnesota Department of Human Services (DHS) are required to comply with federal and state laws that protect the privacy and security of individually identifiable client information.

    Responsibility to Protect Private Data
    You are responsible to protect individually identifiable information about applicants for, or enrollees in, DHS services and program benefits.

    IMPORTANT: Privacy protection applies to Minnesota Family Planning Program (MFPP) eligibility and benefits information. This information is private data on individuals and cannot be released to anyone other than the subject of the data without the data subject’s consent, or unless the law otherwise allows.

    Responsibility to Protect Privacy of Minors
    Remember that minors may apply for the MFPP without parental consent.

    IMPORTANT: Do not release information about a minor’s MFPP eligibility or benefits to a parent, guardian or caretaker without the minor’s informed consent.

    In addition to MHCP confidentiality protection, MFPP applicants and recipients also have the following protections:

  • • MFPP services do not appear on any explanations of medical benefits (EMOBs) to the recipient or recipient’s family. MFPP applicants and recipients may choose to receive notices at an address other than a home address
  • • MFPP applicants and recipients are not required to provide information about their third party liability (other insurance) if they are concerned it may compromise their safety or privacy. If no other insurance is listed when verifying eligibility on MN–ITS do not bill the insurance, even if you have a record of that insurance from a previous visit to your office. Only bill other insurance if the insurance is listed on the current eligibility response
  • Covered Services

    All MFPP procedure codes are available on the Minnesota Family Planning Program (MFPP) Procedure Codes list. Refer to Family Planning Codes with Increased Rates (PDF) for a list of the codes that receive the legislative rate increases.

    Verify Eligibility

    Use an MFPP recipient’s Approval Notice as proof of MFPP presumptive eligibility. After the initial three business days, verify eligibility and obtain the recipient’s ID number using MN–ITS. The system will denote MFPP eligibility with major program code FP. If the recipient is ineligible or you cannot obtain the ID number, contact an MFPP Eligibility Specialist at 651-431-3480 or 1-888-702-9968.

    MFPP covers only family planning related services and supplies, and treatment of sexually transmitted infections (STIs) diagnosed in conjunction with a family planning service (listed below):

  • • Family planning office visits, exams, counseling and education
  • • Contraceptive medications and supplies
  • • Pharmacy services
  • • Voluntary sterilization
  • • Laboratory tests
  • • Diagnosis, testing, and treatment of STIs found during a family planning visit
  • • HIV testing and counseling
  • Mammograms are not a covered MFPP service. For women who require a mammogram, the Minnesota Department of Health (MDH) SAGE Program may be an option if they meet program requirements. Recipients may be eligible for both the SAGE Program and MFPP.

    Report all primary MFPP services with a primary ICD diagnosis code in the V25 – V25.9 range.

    Refer to Sterilization for service, consent, and timeline requirements.

    Contact the Pharmacy before you fax both sides of the MFPP Rx Form available in MN–ITS, (do not give to the recipient) and a copy of the recipients short term approval letter to the pharmacy. Pharmacies need to be prepared to accept prescriptions and immediately dispense medications and supplies listed on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period.

    Pharmacy Services

    MHCP asks pharmacies to work with the MFPP provider and dispense the medications and supplies indicated on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period.

    Certified MFPP providers prescribing medication or supplies must:

  • • Contact the Pharmacy before faxing both sides of the MFPP Rx Form (available in MN–ITS) and a copy of the recipients short term approval letter to the pharmacy
  • • Give presumptively eligible recipients the MFPP Short-Term Approval Notice to take with them to the pharmacy. Provide at least 2 of 3 identifiers (recipient first and last name, date of birth, SSN) for the pharmacy to verify recipient MFPP eligibility using MN–ITS or POS
  • • Pharmacies must be prepared to accept prescriptions and immediately dispense medications and supplies listed on the MFPP Rx Form during a recipient’s MFPP presumptive eligibility period
  • • Only the medication and supplies listed on the MFPP Rx Form are covered at the pharmacy for this program
  • MHCP asks pharmacies to wait three business days to bill for the initial dispense of MFPP medication and supplies, to allow the recipient’s eligibility status to appear in the MHCP system

    MHCP reimburses pharmacies for MFPP related medications and supplies during the presumptive eligibility period, even if it is later determined the recipient was not eligible for more than the initial two months of MFPP.

    Contraceptive and Medication Supplies

    MFPP covers the following contraceptives, anti-infectives, and antifungals dispensed at a pharmacy:

    MFPP Contraceptives

    MFPP Anti-Infectives and Antifungals

    *generic Kariva (21-5)

    *Acyclovir 200mg 400mg 800mg

    *generic Loestrin (1.0-0.02) (1.5-0.03)

    *Amoxicillin 250mg 500mg

    generic LoEstrin FE (1.0-0.02) (1.5-0.03)

    *Azithromycin 250mg 500mg

    *generic Alesse-28 (0.1-0.2)

    Benzoin

    *generic Triphasil-28 (6-5-10)

    Benzoin Compound

    *generic Modicon (0.5-0.035)

    Benzoin/Isopropyl Alcohol

    *genericNordette-28 (0.15-0.03)

    Cefixime 400mg

    *generic Ortho Cept (0.15–0.03)

    Ceftriaxone (IM) 250mg 500mg 1gm

    *generic Ortho Micronor (0.35)

    *Ciprofloxacin 250mg 500mg 750mg

    *generic Ortho Novum 7/7/7 (7-7-7)

    *Clindamycin 150mg

    *generic Ortho Tri-Cyclen (7 days x 3)

    *Doxycycline hyclate 50mg 75mg 100mg

    *generic Ovcon (0.4–0.035)

    *Erythromycin 250mg 333mg 500 mg

    Ovral-21 (0.5-0.05)

    Famciclovir 250mg 500mg

    *generic Lo/Ovral-28 (0.3-0.03)

    Imiquimod

    *generic Demulen 1/35E (1.0-0.035)
    1/50E (1.0-0.05)

    Levofloxacin 250mg 500mg

    *generic Ortho-Novum (1.0-0.035) (1.0-1.05)

    *Metronidazole 0.75% 250mg 500mg

    *generic Ortho-Cyclen (0.25-0.035)

    Nitrofurantoin 25 mg 50 mg 100 mg

    *generic Seasonale (0.15-0.03)

    Ofloxocin 300mg 400mg

    *generic Seasonique (0.15-.0.3)

    Podofilox 0.5%

    *generic Yasmin (0.03-3)

    Podophyllum Resin 0.25%

    *generic Yaz (0.2-3)

    *Probenecid 500mg

    Emergency contraceptive - Plan B generic

    *Sulfamethox/Trimethprim 800/160mg

    Diaphragm

    Trichloroacetic Acid

    Cervical Cap

    Clotrimazole tablet (Femcare) 100mg

    Male or Female Condom

    *Clotrimazole cream 21gm 22.2gm 45gm
    1% 2%

    Nuvaring

    *Fluconazole 50mg 100mg 150mg 200mg

    Ortho Evra Patch

    Miconazole suppository 100mg 200mg

    Other Contraceptive Supply – Spermicide

    Micolazole cream 45 mg 2% 4%

     

    Miconazole 200mg/2% combo pack

     

    Terconazole 80 mg (Terazol 3)

     

    *Terconazole 0.40% (Terazol 7 cream)

     

    *Terconazole 0.80% (Terazol 3 cream)

     

    Tindamax (for Metronidazole intolerance) 250 mg 500 mg

    *MFPP will pay at generic MAC

    Lab Services

    Refer to the Lab Services section when ordering or referring lab tests.

    Certified MFPP providers may perform or order lab tests found in MFPP Procedure Codes List above that are performed during the PE period under the conditions that the MFPP-certified provider found the recipient presumptively eligible.

    Secondary MFPP Services

    Applicable secondary MFPP procedure codes are listed on the last page of the Minnesota Family Planning Program (MFPP) Procedure Codes list. Listed secondary services are covered only when they meet one of the following:

  • • Provided on the same date of service as the primary family planning services and billed with a primary diagnosis code in the V25 – V25.9 range
  • • Provided as follow-up to a previous primary family planning visit within the preceding 180 days, if the recipient is still eligible on MFPP, and reported with the most appropriate ICD primary diagnosis code
  • Non-Covered Services

    MFPP does not cover the full MHCP benefit set. MFPP does not cover the following services:

  • • Pregnancy-related services beyond the original diagnosis
  • • Treatment for HIV/AIDS
  • • Reversal of voluntary sterilization
  • • Fertility drugs and all associated services
  • • Artificial insemination, including in-vitro fertilization
  • • Family planning services provided in an inpatient hospital setting
  • • Abortions (contraceptives provided immediately following an abortion are not considered part of the abortion service and are covered by MFPP)
  • • Pharmacy services for Medicare D dual eligible
  • Billing

    MFPP reimbursement rates are the same as MHCP fee for service reimbursement rates. Recipients may not be charged or billed for MFPP services. MFPP services have no copays.

  • • Bill using MN–ITS 837P or the 837I
  • • FQHC/RHCs: Bill using the MN–ITS 837P. Indicate each service provided. MHCP will reimburse your encounter rate
  • • For recipients eligible for MFPP (major program code FP), MHCP will cover only the services/drugs/supplies described in this section
  • Bill other insurance only if insurance is listed on the current eligibility response.

    Lab Services

    Refer to the Lab Services section when billing lab tests.

    MFPP-certified physicians treating recipients that have presumptive eligibility (PE) for MFPP, may bill for lab tests or services when:

    • The tests or services are performed at your facility

    • The tests or services are performed on the same day as other family planning services

    • The primary diagnosis is in the V25 – V25.9 range

    If you send lab tests to a reference or independent lab provider, refer to the Reference and Outside Lab Services policy in the Lab Services section. Give the lab provider the following information so the lab can bill for the service:

  • • A copy of the recipient’s MFPP Short-Term Approval Notice (gives the lab provider at least two of three recipient identifiers (first and last name, date of birth, SSN) so the lab can verify eligibility on EVS or MN–ITS
  • • Primary diagnosis code in the V25 – V25.9 range
  • • Secondary diagnosis codes as appropriate
  • • The primary ordering provider’s NPI
  • If an MFPP recipient does not have an MHCP ID number:

  • • Perform the lab tests
  • • Wait 3 business days
  • • Use the information from the MFPP provider to obtain the recipients MHCP ID number
  • • Bill MHCP for the lab tests performed using the primary diagnosis code in the V25 – V25.9 range from the referring/ordering provider
  • All MHCP-enrolled labs are required to perform lab tests ordered for recipients during the PE period and after a recipient’s MFPP ID number is determined and available on EVS or MN–ITS (usually 3 business days after the physician determines PE).

    Legal References

    MS 9505.5305 (definitions)
    MS 9505.5310
    (eligibility, application, enrollment, and documentation)
    MS 9505.5315
    (providers of family planning services)
    MS 9505.5325
    (appeals)
    Section 1902(a)(32) of the Social Security Act
    (Reference Labs)

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