Common use of Family Planning Clause in Contracts

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO must provide its Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 fee- for-service basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must shall not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees recipients must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO must provide its Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrolleesmembers. The MCO MCOs must also educate enrollees members regarding the positive impact of coordinated care on their health outcomes, so enrollees members will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS fee-for- service rate appropriate to the provider type (current family planning services fee schedule available from BMSDHHR). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the The MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO must provide its Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMSDHHR). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider PCP or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider PCP for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, MCOs are required to provide timely reimbursement for out-of-network family planning and related sexually transmitted disease (STD) services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from the Department). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO must provide its Medicaid planning information and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: records confidential in favor of the types of family planning services availableindividual patient, their right to access these services in even if the patient is a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS)minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the The MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMSDHHR). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the The MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 basis.3 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMSDHHR). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, the availability of long-acting reversible contraceptives (LARC), their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from DHHR). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO must provide its Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 fee-for-service basis.3 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by 3 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity shall not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid recipients must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrolleesmembers. The MCO MCOs must also educate enrollees members regarding the positive impact of coordinated care on their health outcomes, so enrollees members will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS fee-for-service rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services. All MCOs must reimburse out-of-network providers for family planning services rendered to enrollees. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The following are the conditions under which family planning providers will be reimbursed for family planning services provided to Medicaid enrollees: 1. The family planning provider must be qualified to provide family planning services based on licensed scope of practice; 2. The family planning provider must submit claims on appropriate MCO-specific billing forms; and 3. The family planning provider must provide medical records sufficient to allow the MCO to meet its case management responsibilities. If an enrollee refuses the release of medical information, the out-of-network provider must submit documentation of such refusal. In order to avoid duplication of services, promote continuity of care, and achieve the optimum clinical outcome for Medicaid enrollees, MCOs should encourage out-of- network family planning providers to coordinate services with MCO providers and to educate MCO enrollees to return to MCO providers for continuity of care. If a non-participating provider of family planning services detects a problem outside of the scope of services listed above, the provider must refer the enrollee back to the MCO. Non-participating providers are responsible for keeping family planning information confidential in favor of the individual patient even if the patient is a minor. The MCO is not responsible for the confidentiality of medical records maintained by non-participating providers.

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill xxxx the MCO and be paid on a FFS basis.4 fee-for-service basis.5 Family planning services are defined in Article II of this contract. The MCO must shall give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must shall make a reasonable effort to Subcontract subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must shall reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must shall reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. The MCO MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrolleesmembers. The MCO MCOs must also educate enrollees members regarding the positive impact of coordinated care on their health outcomes, so enrollees members will 5 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity shall not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid recipients must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS fee-for- service rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation shall keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must shall also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.. All MCOs must reimburse out-of-network providers for family planning services rendered to enrollees. Unless otherwise negotiated, the MCO shall reimburse providers of family planning services at the Medicaid rate. The following are the conditions under which family planning providers will be reimbursed for family planning services provided to Medicaid enrollees:

Family Planning. In accordance with 42 CFR §438.206(b)(7), the MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid and WVCHIP enrollees are entitled to obtain all Medicaid and WVCHIP covered family planning services without prior authorization through any Medicaid and WVCHIP provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide its their Medicaid and WVCHIP enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, the MCO MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. The MCO MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, the MCO is MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.