All MHCP members with Medical Assistance (MA) and MinnesotaCare are eligible for sterilization services if they meet the following criteria. Emergency Medical Assistance (EH) does not cover sterilization services.

· At least 21 years old at the time the Consent for Sterilization form is signed.

· Mentally competent

· Not institutionalized

· Voluntarily sign the Consent for Sterilization (PDF) form. MHCP will not accept a consent form signed by a guardian, conservator or anyone other than the person to be sterilized.

Retroactive Eligibility

Sterilization form requirements cannot be retroactively met. When a member without financial resources or insurance coverage requests sterilization and indicates that they are considering applying for or has applied for MHCP, the provider may obtain informed consent, complete a Consent for Sterilization form, and allow for the 30-day waiting period. The informed consent, completed Consent for Sterilization form, and 30-day waiting period requirements must still be met.

If a member becomes retroactively eligible for MHCP and paid for the sterilization procedure within the retroactive period, the provider must reimburse the member the full amount paid and may then bill MHCP if there is a valid sterilization consent form and the 30-day waiting period was observed.

Covered Services

All sterilization procedures must follow MHCP sterilization requirements. The following sterilization services are covered:

· Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; no other symptoms (NOS)

· Anesthesia, tubal ligation/transection

· Hysteroscopy, surgical with bilateral fallopian tube cannulation to induce occlusion

· Laparoscopy, surgical; with fulguration of oviducts (with or without transection)

· Laparoscopy, surgical; with occlusion of oviducts by device (for example, band, clip or Falope ring)

· Ligation or transection of fallopian tube(s), abdominal or vaginal approach

· Occlusion of fallopian tube(s) by device (for example, band, clip, Falope ring) vaginal or suprapubic approach

· Vasectomy, unilateral or bilateral (separate procedure), including postop semen exam

The following criteria must be met for a sterilization to be covered by MHCP:

· The member must be:

· At least 21 years old at the time the sterilization consent form is signed

· Mentally competent

· Not institutionalized

· Voluntarily signing the Consent for Sterilization form. MHCP will not accept a sterilization consent form signed by a guardian, conservator or anyone other than the individual to be sterilized.

· Consent form signature, date and timeline requirements:

· Dates: Dates corresponding to signatures must be filled in by the person whose signature is on the preceding line (patient, interpreter, person obtaining consent, or physician). Consent for Sterilization form dates must not be typed onto the form or filled in by someone other than the signatory. Dates can be changed only to correct a clerical error. If, for example, a person writes 1/8/2019 instead of 1/8/2020, the error should be struck through, but not obliterated, and the correct date entered. The reason for the change should be evident.

· Member to be sterilized: The member to be sterilized must sign and date the sterilization consent form. At least 30 days, but not more than 180 days, must pass between the date the member signed the sterilization consent form and the date of surgery.

· Interpreter: If an interpreter was provided, the interpreter must sign and date the sterilization consent form after the member signs but before the day of surgery.

· Person obtaining consent: The person obtaining the consent must sign and date the sterilization consent form after the member signs but before the day of surgery. The person obtaining the consent certifies that, by signing the sterilization consent form, they orally explained the requirements for informed consent and, to the best of their knowledge and belief, the member to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

· Physician: The physician who performs the sterilization procedure must sign and date the sterilization consent form shortly before (no more than 15 days) the day of surgery, or at any time after the surgery. The physician certifies, by signing the sterilization consent form, that they advised the member to be sterilized that no federal benefits will be withdrawn if the member chooses not to be sterilized, explained the requirements for informed consent, and, to the best of their knowledge and belief, the member to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

Noncovered Services

MHCP does not cover:

· Reversal of voluntary sterilization

· Sterilization of a mentally incompetent member

· Sterilization of a member institutionalized voluntarily, civilly committed or court ordered, in a(n):

· Intermediate care facilities for people with developmental disabilities or related condition (ICF/DD-RC)

· Regional treatment centers that are not institutions for mental disease (RTC, not IMD)

· RTC-IMD

· IMD

· Correctional facilities (county or noncounty)

· Chemical dependency rehabilitation programs

· Residential facilities for mentally ill persons

· Sterilization of anyone who consented to sterilization and was under 21 years old at the time of consent

· Sterilization without the member’s informed consent, including sterilization in which a person has given consent for the member, including court-ordered sterilization of a mentally incompetent or institutionalized member

· Sterilizations consented to by members:

· In labor or childbirth

· Seeking to obtain or obtaining an abortion

· Under the influence of alcohol or other substances that affect the member’s state of awareness

· In a situation that the provider believes that the member is unable to give informed consent

Service Requirements

Providers must:

· Obtain consent

· Be in possession of a completed and signed Consent for Sterilization form

Required Counseling

The person obtaining consent for the sterilization must answer the member’s questions about the procedure, provide a copy of the Consent for Sterilization form and explain the requirements for informed consent that are listed on the consent form. Shortly before the sterilization, the physician who will perform the procedure must explain the requirements for informed consent that are listed on the Consent for Sterilization form.

Interpreter Services

The provider must provide a:

· Language interpreter to ensure that the information about the sterilization is accurately and clearly communicated for members who do not understand English.

· Sign language interpreter to ensure that information is accurately and clearly communicated to a member who is hearing impaired.

Obtaining Consent

The Code of Federal Regulations outlines requirements, including use of the Consent for Sterilization form, for obtaining informed consent. Providers must meet all requirements for MHCP to reimburse for performing sterilization procedures. These requirements apply to all MHCP members (MA and MinnesotaCare). Under no circumstances will MHCP waive the requirements.

It is the physician’s responsibility to obtain informed consent. If the physician does not believe the member can give informed consent, the physician should not perform the sterilization or may request additional information to determine whether the member is capable of giving informed consent (such as a psychiatric evaluation).

Transfer of Consent

If a member moves or changes providers, the sterilization consent form may be transferred to the new provider. However, the physician who performs the surgery must complete the physician section and sign within the appropriate time limits.

Consent for Sterilization Form

The Consent for Sterilization form must be completed for MHCP to reimburse providers for performing sterilization procedures. This requirement applies to all MHCP members with MA and MinnesotaCare. EH does not cover sterilization services.

Different guidelines apply for hysterectomies. Refer to Hysterectomy under Reproductive Health/OB-GYN in the MHCP Provider Manual.

The following links go to the Consent for Sterilization form and U.S. Department of Health and Human Services sterilization fact sheets from the Centers for Disease Control and Prevention (CDC):

· Consent for Sterilization (PDF)

· CDC Permanent Contraception webpage

If a facility or provider needs to reformat the Consent for Sterilization form, a disclaimer must be added in the top left corner of the header that states the following:

“___(insert facility or provider name)_______ certifies the text contained in this Sterilization Consent Form complies with the text in 42 CFR Part 441, Subpart F Appendix.”

The facility or provider must complete a Consent for Sterilization form for each MHCP member who requests a sterilization procedure (refer to Obtaining Consent). The Consent for Sterilization form creates an opportunity for providers to obtain informed consent by giving the member:

· An opportunity to ask questions about the sterilization process

· An oral explanation about the procedure and any procedural risks according to sterilization consent form requirements

· A copy of the Consent for Sterilization form

· Advice that the decision to be sterilized will not affect future care or benefits, and the sterilization will not be performed for at least 30 days, except in the case of premature delivery or emergency abdominal surgery

The member cannot consent to sterilization and the provider cannot accept a Consent for Sterilization form when a member is:

· In labor or childbirth

· Seeking to obtain or obtaining an abortion

· Under the influence of alcohol or other substances that affect the member’s state of awareness

· In a situation that the provider believes that the member is unable to give informed consent

Exceptions to Timelines

The following exceptions apply to the Consent for Sterilization form timelines:

· Emergency abdominal surgery: When the member to be sterilized requires emergency abdominal surgery, the sterilization may be covered at the time of emergency abdominal surgery if at least 72 hours have passed since the member signed the consent form.

· An emergency Cesarean section is not considered emergency abdominal surgery.

· Premature delivery: When the member to be sterilized goes into premature delivery, the sterilization may be covered if at least 72 hours from the “From date” of admission have passed since the member signed the consent form and the member signed it at least 30 days before the expected date of delivery.

The Instructions for use of alternative final paragraph section (under the Physician’s Statement heading of the Consent for Sterilization form) requires a choice between paragraph one or paragraph two. If you select paragraph two, provide information about the premature delivery or emergency abdominal surgery.

Billing

· Bill electronically

· Fax a copy of the Consent for Sterilization form for all sterilization claims, including physician, anesthesiologist, CRNA and hospital or surgical center following the instructions on the Electronic claim attachments webpage.

· Use the appropriate diagnosis code

For Minnesota Family Planning Program (MFPP) members, refer to the specific codes on the Minnesota Family Planning Program (MFPP) Healthcare Common Procedure Coding System (HCPCS) Codes webpage.

Definitions

Institutionalized individual
An individual who is involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental health or other facility for the care and treatment of mental illness, or confined under a voluntary commitment in a mental health or other facility for the care and treatment of mental illness.

Mentally incompetent individual
An individual who is declared mentally incompetent by a federal, state or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.

Note: A member who has a legal guardian or conservatorship is considered a mentally incompetent individual.

Legal References

Minnesota Statutes, 524.5 – 313 Sterilization: Powers and duties of guardian
Code of Federal Regulations, title 42, subpart F Sterilizations
Code of Federal Regulations, title 42, section 441.257 Informed Consent for sterilization
Code of Federal Regulations, title 42, section 441.258 Consent form requirements

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