Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.21 - Family planning services

Current through June 24, 2024
(1) COVERED
				SERVICES.
(a)
General.
Covered family planning services are the services included in this subsection
				when prescribed by a physician and provided to a recipient, including initial
				physical exam and health history, annual office visits and follow-up office
				visits, laboratory services, prescribing and supplying contraceptive supplies
				and devices, counseling services and prescribing medication for specific
				treatments. All family planning services performed in family planning clinics
				shall be prescribed by a physician, and furnished, directed or supervised by a
				physician, registered nurse, nurse practitioner, licensed practical nurse or
				nurse midwife under s.
				441.15(1)
				and (2) (b), Stats.
(b)
Physical examination.
An
				initial physical examination with health history is a covered service and shall
				include the following:
1. Complete
				obstetrical history including menarche, menstrual, gravidity, parity, pregnancy
				outcomes and complications of pregnancy or delivery, and abortion
				history;
2. History of significant
				illness-morbidity, hospitalization and previous medical care, particularly in
				relation to thromboembolic disease, any breast or genital neoplasm, any
				diabetic or prediabetic condition, cephalalgia and migraine, pelvic
				inflammatory disease, gynecologic disease and venereal disease;
3. History of previous contraceptive
				use;
4. Family, social, physical
				health, and mental health history, including chronic illnesses, genetic
				aberrations and mental depression;
5. Physical examination. Recommended
				procedures for examination are:
a. Thyroid
				palpation;
b. Examination of
				breasts and axillary glands;
c.
				Auscultation of heart and lungs;
d.
				Blood pressure measurement;
e.
				Height and weight measurement;
f.
				Abdominal examination;
g. Pelvic
				examination; and
h. Examination of
				extremities.
(c)
Laboratory and other diagnostic
				services.
Laboratory and other diagnostic services are covered
				services as indicated in this paragraph. These services may be performed in
				conjunction with an initial examination with health history, and are the
				following:
1. Routinely performed procedures:
a. CBC, or hematocrit or
				hemoglobin;
b.
				Urinalysis;
c. Papanicolaou smear
				for females between the ages of 12 and 65;
d. Bacterial smear or culture (gonorrhea,
				trichomonas, yeast, etc.) including VDRL - syphilis serology with positive
				gonorrhea cultures; and
e.
				Serology;
2. Procedures
				covered if indicated by the recipient's health history:
a. Skin test for TB;
b. Vaginal smears and wet mounts for
				suspected vaginal infection;
c.
				Pregnancy test;
d. Rubella
				titer;
e. Sickle-cell
				screening;
f. Post-prandial blood
				glucose; and
g. Blood test for
				cholesterol, and triglycerides when related to oral contraceptive
				prescription;
3.
				Diagnostic and other procedures not for the purpose of enhancing the prospects
				of fertility in males or females;
a.
				Endometrial biopsy when performed after a hormone blood test;
b. Laparoscopy;
c. Cervical mucus exam;
d. Vasectomies;
e. Culdoscopy; and
f. Colposcopy;
4. Procedures relating to genetics,
				including:
a. Ultrasound;
b. Amniocentesis;
c. Tay-Sachs screening;
d. Hemophilia screening;
e. Muscular dystrophy screening;
				and
f. Sickle-cell screening;
				and
5. Colposcopy,
				culdoscopy, and laparoscopy procedures which may be either diagnostic or
				treatment procedures.
(d)
Counseling services.
Counseling services in the clinic are covered as indicated in this paragraph.
				These services may be performed or supervised by a physician, registered nurse
				or licensed practical nurse. Counseling services may be provided as a result of
				request by a recipient or when indicated by exam procedures and health history.
				These services are limited to the following areas of concern:
1. Instruction on reproductive anatomy and
				physiology;
2. Overview of
				available methods of contraception, including natural family planning. An
				explanation of the medical ramifications and effectiveness of each shall be
				provided;
3. Counseling about
				venereal disease;
4. Counseling
				about sterilization accompanied by a full explanation of sterilization
				procedures including associated discomfort and risks, benefits, and
				irreversibility;
5. Genetic
				counseling accompanied by a full explanation of procedures utilized in genetic
				assessment, including information regarding the medical ramifications for
				unborn children and planning of care for unborn children with either diagnosed
				or possible genetic abnormalities;
6. Information regarding teratologic
				evaluations; and
7. Information and
				education regarding pregnancies at the request of the recipient, including
				pre-natal counseling and referral.
(e)
Contraceptive methods.
Procedures related to the prescription of a contraceptive method are covered
				services. The contraceptive method selected shall be the choice of the
				recipient, based on full information, except when in conflict with sound
				medical practice. The following procedures are covered:
1. Those related to intrauterine devices
				(IUD):
a. Furnishing and fitting of the
				device;
b. Localization procedures
				limited to sonography, and up to 2 x-rays with interpretation;
c. A follow-up office visit once within the
				first 90 days of insertion; and
d.
				Extraction;
2. Those
				related to diaphragms:
a. Furnishing and
				fitting of the device; and
b. A
				follow-up office visit once within 90 days after furnishing and
				fitting;
3. Those
				related to contraceptive pills:
a. Furnishing
				and instructions for taking the pills; and
b. A follow-up office visit once during the
				first 90 days after the initial prescription to assess physiological changes.
				This visit shall include taking blood pressure and weight, interim history and
				laboratory examinations as necessary.
(f)
Office visits.
Follow-up
				office visits performed by either a nurse or a physician and an annual physical
				exam and health history are covered services.
(g)
Supplies.
The following
				supplies are covered when prescribed:
1. Oral
				contraceptives;
2.
				Diaphragms;
3. Jellies, creams,
				foam and suppositories;
4. Condoms;
				and
5. Natural family planning
				supplies such as charts.