Payment: Visits

(A) The payment for a family planning visit includes payment for the administrative operation of the family planning agency and for all aspects of service delivery, excluding laboratory tests, supplies, and drugs. Other than payment for laboratory tests, supplies, and drugs, no additional fees will be paid by the MassHealth agency. (B) For each member encounter, the MassHealth agency pays for only one of the following types of visits. (1) Comprehensive Visit. The MassHealth agency pays for a comprehensive visit only when the encounter is an initial, annual, or extended visit. An initial or annual visit must include all of the medical, laboratory, and counseling services required in 130 CMR 421.412(A) and 421.413. The MassHealth agency pays for only one initial or annual visit per member per year. An encounter is considered to be an extended visit when it is not routine in nature because extensive medical attention is necessary. Such a visit must last approximately 30 minutes. For an extended visit, the need for such services and the time elapsed must be documented in the medical record by the physician. The MassHealth agency pays for HIV pre- and post-test counseling services in addition to a comprehensive visit. (2) Routine Visit. The MassHealth agency pays for a routine visit when the encounter is a return, follow-up, or other visit that is neither comprehensive nor minimal. A routine visit must include all of the medical, laboratory, and counseling services required in 130 CMR 421.412(B) and 421.413. The MassHealth agency pays for HIV pre- and post-test counseling services in addition to a routine visit. (3) Minimal Service Visit. The MassHealth agency pays for a minimal service visit when the encounter is a return visit consisting of counseling services only, or of a brief medical encounter and counseling services. The purpose of a minimal service visit is to reinforce contraceptive instructions, to monitor the member's use of a contraceptive method, or to provide education and counseling. A minimal service visit may not be billed in addition to HIV pre- and post-test counseling services. (C) The MassHealth agency does not pay for a visit for the sole purpose of replenishing a member's supply of contraceptives. In this case, only the cost of the contraceptive supplies is payable. Division of Medical Assistance SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS PAGE FAMILY PLANNING AGENCY MANUAL TRANSMITTAL LETTER DATE (D) The family planning agency may bill for either a visit or a treatment/procedure, but may not bill for both a visit and a treatment/procedure for the same member on the same date when the visit and the treatment/procedure are performed in the same location. Examples of treatment/procedures are a vasectomy, a colposcopy, and a colposcopy with a biopsy. (E) The family planning agency may be paid for a maximum of one HIV pre-test counseling visit and one HIV post-test counseling visit per member per test per day. The MassHealth agency pays for a maximum of four HIV pre-test counseling visits and four HIV post-test counseling visits per calendar year.