Reproductive Health/OB-GYN - Minnesota Family Planning Program (MFPP) (2025)

Revised: March 12, 2024

·Overview

·Eligible Providers

·Eligible Members

·Covered Services

·Noncovered Services

·Billing

·Legal References

Overview

This section includes Minnesota Health Care Programs (MHCP) coverage and billing policy for the Minnesota Family Planning Program (MFPP) providers. For detailed information for determining eligibility for MFPP, refer to the Certified MFPP Provider Training Guide (DHS-7421) (PDF).

MHCP offers MFPP as a separate set of family planning services. Provider, member and service delivery requirements are not the same for MFPP and non-MFPP MHCP family planning services. Refer to the Reproductive Health/OB-GYN section in the MHCP Provider Manual for links to other related services.

One of the main goals of the MFPP is to reduce the number of unintended births, thereby reducing costs to Minnesota’s publicly funded health care programs.

Eligible Providers

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

·Ambulatory surgical centers

·Anesthesiologists and certified registered nurse anesthetists (CRNAs)

·Certified nurse midwives

·Clinical nurse specialists

·Community health clinics (CHC)

·Family planning agencies

·Federally qualified health centers (FQHC)

·Laboratories

·Nurse practitioners

·Outpatient hospital departments

·Pharmacies

·Physician assistants

·Physician-directed clinics

·Physicians

·Public health clinics (PHC)

·Rural health clinics (RHC)

·Tribal and Federal Indian Health Services (IHS)

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 member who is less than 12 years of age. Follow state requirements for dispensing prescription drugs.

Presumptive Eligibility (PE)

PE is a short-term period of eligibility determined at the point of service by a certified MFPP provider. PE begins on the day a provider verifies and determines eligibility. PE ends on the day the full MFPP determination is completed, or the last day of the month following the month it was approved, whichever is earlier. PE is allowed one time in a 12-month period.

Both the Short-Term Approval Notice (DHS-5701A) (PDF) and the Short-Term Denial Notice (DHS-5701B) (PDF) are linked in the Certified MFPP Provider Training Guide (DHS-7421) (PDF).

At the time a PE determination is made, the certified MFPP provider gives the applicant a MFPP Short-Term Approval Notice, available online through the MN–ITS website. 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 or the electronic verification system (EVS). If you determine the person is not eligible for PE, give the person a denial notice. Then forward the application to DHS to determine whether the person is eligible for any other health care coverage.

MFPP Provider Certification

Certified MFPP providers are individuals and clinics providing primary family planning services that are certified by Minnesota Department of Human Services (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.

Certified MFPP providers must follow the MFPP program-specific requirements defined in the online Certified MFPP Provider Training Guide (DHS-7421) (PDF), and must submit the completed Minnesota Family Planning Program (MFPP) Application Packet (DHS-4773) (PDF) to:

DHS-Provider Enrollment
PO Box 64987
St. Paul, MN 55164-0987Fax forms to: 651-431-7462

For presumptive eligibility determination, please call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411. Press option 1 to reach EVS.

Referrals to Other Providers

·Physicians, advanced practice registered nurses (APRNs), clinics and family planning agencies serve as the primary care providers for member reproductive health services. Providers must make available to MFPP-eligible members all services in the MFPP benefit package either directly or by referral.

·Refer members only to MHCP-enrolled providers, as members must not be billed.

·Provide the primary diagnosis in the applicable range, and any secondary diagnosis that applies, and at least two of three identifiers (member first and last name, date of birth or social security number) sufficient for an outside lab or other providers to verify member MFPP eligibility using MN–ITS and bill for services performed.

When members require access to primary care services, direct them to the MHCP Provider Directory. Refer members who want other health care coverage to the MNsure website.

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

Eligible Members

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 member for MFPP must meet the following criteria:

·Be a Minnesota resident

·Be a citizen or a qualified noncitizen

·Have income at or below 200 percent federal poverty guidelines (FPG) (individuals under age 21 are eligible based on their own income)

·Is not pregnant

·Is not institutionalized

Initial presumptive (short-term) eligibility begins on the day the MFPP provider determines that a member is eligible, through the last day of the following month. MHCP will determine the member’s continued MFPP eligibility. If found eligible, the member has MFPP coverage for an additional 12 months. MFPP eligibility ends before the annual renewal if the member has one of the following occur:

·Is no longer a Minnesota resident

·Voluntarily terminates eligibility

·Becomes pregnant

·Becomes institutionalized

Confidentiality

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

Responsibility to Protect Private Data
Providers 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
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 members also have the following protections:

·MFPP services do not appear on any explanations of medical benefits (EMOBs) to the member or member’s family.

·MFPP applicants and members may choose to receive notices at an address other than a home address.

·MFPP applicants and members 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) Healthcare Common Procedure Coding System (HCPCS) Codes webpage. Refer to Family Planning Codes with Increased Rates for a list of the codes that receive the legislative rate increases.

Verify Eligibility

Use an MFPP member’s approval notice as proof of MFPP presumptive eligibility. After the initial three business days, verify eligibility and obtain the member’s ID number using MN–ITS. The system will denote MFPP eligibility with major program code FP. If the member is ineligible or you cannot obtain the ID number, contact an MFPP Eligibility Specialist at 651-431-3480 or 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 members who require a mammogram, the Minnesota Department of Health (MDH) SAGE Program may be an option if they meet program requirements. Members may be eligible for both the SAGE Program and MFPP.

Report all primary MFPP services with a primary ICD diagnosis code in the Z30.011 - Z30.9 range.

Refer to Sterilization in the Reproductive Health/OB-GYN section in the MHCP Provider Manual for service, consent and timeline requirements.

Contact the pharmacy before faxing both sides of the MFPP Rx Form available in MN–ITS, (do not give to the member) and a copy of the member’s 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 member’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 member’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 members short-term approval letter to the pharmacy.

·Give presumptively eligible members the MFPP short-term approval notice to take with them to the pharmacy.

·Provide at least two of three identifiers (member first and last name, date of birth or social security number) for the pharmacy to verify member’s 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 member’s MFPP presumptive eligibility period.

·Remember 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 member’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 member was not eligible for more than the initial two months of MFPP.

Contraceptive and Medication Supplies

Refer to the MHCP NDC Search tool to see the list of covered contraceptives, anti-infectives and antifungals dispensed at a pharmacy. To search for a product use the NDC or product name and change the major program to “FP”. MFPP will pay at the maximum allowable cost (MAC) for generic medications.

Refer to the following when billing for family planning services:

·Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the Provider Basics for general billing information.

·Pharmacies: Bill Point of Sale (POS) for drugs; use the MN–ITS 837P for Equipment and Supplies

·Tribal and Indian Health Services (IHS), family planning agencies and community health clinics (CHCs) dispensing oral contraceptives:

·Oral contraceptives and hormonal emergency contraceptives (for example, Plan B, EZ Contra):

·Use HCPCS code S4993

·Bill up to a twelve-month supply

·Non-hormonal emergency contraceptives (for example, ulipristal):

·Use procedure code J8499 and diagnosis code Z30.012 to bill emergency contraceptives when billing MFPP

·Use J3490 when billing MA or MinnesotaCare

·If you provide oral contraceptive products (OCPs) and emergency contraceptives (ECs) on the same date of service, list OCPs on one claim line and list EC on a different claim line

Lab Services

Refer to the Laboratory and Pathology Services section of the MHCP Provider Manual 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 member presumptively eligible.

Nonemergency Medical Transportation (NEMT) and Ancillary Services

The MFPP program covers transportation and the related ancillary services for dates of service on and after Jan. 1, 2017. Refer to the NEMT Services (Overview) section for more information.

Secondary MFPP Services

Applicable secondary MFPP procedure codes are listed in the second table on the Minnesota Family Planning Program (MFPP) Healthcare Common Procedure Coding System (HCPCS) Codes webpage. Listed secondary services are covered only when they meet one of the following:

·Secondary services are provided on the same date of service as the primary family planning services and billed with a primary diagnosis code in the applicable range; or

·Secondary services are provided as follow-up to a previous primary family planning visit within the preceding 180 days, if the member is still eligible and receiving MFPP, and reported with the most appropriate ICD primary diagnosis code

Telehealth Services

Telehealth services are covered for MHCP members. Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) (PDF) to the Minnesota Department of Human Services to bill for telehealth services. Review Telehealth Services in the MHCP Provider Manual for more information.

Noncovered 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

Refer to Noncovered Services in the Billing the Member (Recipient) section under Provider Basics in the MHCP Provider Manual for conditions required to bill the member.

Billing

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

·Bill using the MN–ITS 837P or 837I

·FQHCs and RHCs: Bill using the MN–ITS 837P. Indicate each service provided. MHCP will reimburse your encounter rate

·For members eligible for MFPP (major program code FP), MHCP will cover only the services, drugs and supplies described in this section

Bill other insurance only if insurance is listed on the current eligibility response.

Lab Services

Refer to the Laboratory and Pathology Services section of the MHCP Provider Manual when billing lab tests.

MFPP-certified physicians treating members 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 applicable range.

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

·A copy of the member’s MFPP Short-Term Approval Notice that gives the lab provider at least two of three member identifiers (first and last name, date of birth, social security number) so the lab can verify eligibility on EVS or MN–ITS

·Primary diagnosis code in the applicable range

·Secondary diagnosis codes as appropriate

·The primary ordering provider’s NPI

If an MFPP member does not have an MHCP ID number:

·Perform the lab tests.

·Wait three business days.

·Use the information from the MFPP provider to obtain the members MHCP ID number.

·Bill MHCP for the lab tests performed using the primary diagnosis code in the applicable range from the referring/ordering provider.

All MHCP-enrolled labs are required to perform lab tests ordered for members during the PE period and after a member’s MFPP ID number is determined and available on EVS or MN–ITS (usually three business days after the physician determines PE).

Legal References

Minnesota Statutes, 9505.0015 (definitions)
Minnesota Statutes, 9505.0010 – 9505.0015 (eligibility, application, enrollment, and documentation)
Minnesota Statutes, 9505.0280 (family planning services)
Minnesota Statutes, 9505.0130 (appeals)
Code of Federal Regulations, title 42, section 435.214 (eligibility for Medicaid limited to family planning related services)

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