5160-21-02.3 Limited family planning benefit.  

  • Text Box: ACTION: Emergency Text Box: DATE: 12/31/2014 10:23 AM




    5160-21-02.3               Limited family planning benefit.




    (A)  The following definitions apply for the purposes of this limited medicaid benefit:


    (1)   "Pregnancy prevention/contraceptive management services" or "family planning services" are defined in rule 5160-21-02 of the Administrative Code.


    (2)   "Family planning-related services" are medically necessary services identified during a routine or periodic family planning visit that satisfy two criteria:


    (a)   They belong to one of four specific types:


    (i)   Diagnosis of sexually-transmitted diseases or infections (STIs);


    (ii)   Treatment of STIs other than human immunodeficiency virus (HIV) and hepatitis;


    (iii)   Mammography when indicated by a breast examination; or


    (iv)    Vaccinations against human papillomavirus (HPV) or hepatitis B provided in accordance with rule 5160-4-12 of the Administrative Code; and


    (b)   They are provided as part of a family planning visit or within sixty days of the family planning visit where their need was determined.


    (B)   Individuals who meet the eligibility criteria in rule 5160:1-5-40 of the Administrative Code have a limited medicaid benefit that only includes the following:


    (1)   Family planning and family planning-related services listed in the appendix to this rule;


    (2)   Hospital services covered in Chapter 5160-2 of the Administrative Code when provided as a family planning-related service as defined in this rule; and


    (3)     Medicaid-covered, FDA-approved drugs covered in Chapter 5160-9 of the Administrative Code when provided as a family planning-related service as defined in this rule.


    (C)    When submitting claims for services available under the limited family planning benefit, providers must include the information specified in rule 5160-21-02 of the Administrative Code. All claims, including pharmacy claims, for family planning



    and family planning-related services must be submitted with a family planning diagnosis code in the V25 series.

    Effective:                                                             12/31/2014





    Promulgated Under:                           119.03

    Statutory Authority:                           5164.02

    Rule Amplifies:                                  5162.03, 5164.02

    Prior Effective Dates:                         01/01/2012, 12/30/2012 (Emer), 03/28/2013,

    12/18/2013 (Emer), 03/27/2014

Document Information

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Related Chapter/Rule NO.: (1)
Ill. Adm. Code 5160-21-02.3. Limited family planning benefit