CHAPTER 1225. FAMILY PLANNING CLINIC SERVICES

GENERAL PROVISIONS

Sec.


1225.1.    Policy.
1225.2.    Definitions.

SCOPE OF BENEFITS


1225.21.    Scope of benefits for the categorically needy.
1225.22.    Scope of benefits for the medically needy.
1225.23.    Scope of benefits for State Blind Pension recipients.
1225.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1225.41.    General participation requirements.
1225.42.    Additional requirements for hospital outpatient family planning clinics.
1225.43.    Additional requirements for independent family planning clinics.
1225.44.    Participation requirements for out-of-state family planning clinics.
1225.45.    Ongoing responsibilities of providers.

PAYMENT FOR FAMILY PLANNING CLINIC SERVICES


1225.51.    General payment policy.
1225.52.    Conditions of payment.
1225.54.    Noncompensable family planning services.

UTILIZATION CONTROL


1225.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1225.81.    Provider misutilization.

Authority

   The provisions of this Chapter 1225 issued under sections 403 and 443.3(1) of the Public Welfare Code (62 P. S. § §  403 and 443.3(1)), unless otherwise noted.

Source

   The provisions of this Chapter 1225 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.95 (relating to conflicts between general and specific provisions).

GENERAL PROVISIONS


§ 1225.1. Policy.

 The MA Program provides payment for family planning services provided to eligible recipients by hospital outpatient family planning clinics and independent family planning clinics enrolled as providers under the program. Payment for family planning clinic services is subject to this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.

Source

   The provisions of this §  1225.1 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117482).

§ 1225.2. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   CRNP—Certified registered nurse practitioner—An individual currently certified by the State Board of Medicine and the State Board of Nursing as a CRNP within the scope of the Medical Practice Act of 1974 (63 P. S. § §  421.1—421.18) (Repealed).

   FPIS—Family planning invoicing system—A computerized billing system whereby the Family Planning Council or family planning clinic receives payment for several levels of family planning examinations, specific laboratory tests performed at the clinic site and for dispensing specific family planning drugs and devices at the clinic site.

   Family planning services—Diagnosis, treatment, drugs, supplies and related counseling which are provided to individuals of child bearing age to enable the individuals to determine freely the number and spacing of their children.

   Hospital outpatient family planning clinic—A hospital affiliated facility that provides family planning services on an outpatient basis.

   Independent family planning clinic—A free-standing facility operated by a public or private organization which provides family planning services on an outpatient basis.

   Physician—An individual currently licensed by the State Board of Medicine or the State Board of Osteopathic Medicine to practice medicine and surgery under section 10 of the Medical Practice Act of 1974 (63 P. S. §  421.10) (Repealed) or the Osteopathic Medical Practice Act (63 P. S. § §  271.1—271.18).

   Physician assistant—An individual currently certified by the State Board of Medicine or the State Board of Osteopathic Medicine as a physician assistant within the scope of the Medical Practice Act of 1974 (63 P. S. § §  421.1—421.18) (Repealed) or the Osteopathic Medical Practice Act (63 P. S. § §  271.1—271.18).

   Registered nurse—An individual currently licensed in this Commonwealth by the State Board of Nursing to practice professional nursing within the scope of the Professional Nursing Law (63 P. S. § §  211—225).

Source

   The provisions of this §  1225.2 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

SCOPE OF BENEFITS


§ 1225.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for the family planning services listed in MA Program fee schedule.

Source

   The provisions of this §  1225.21 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117483).

§ 1225.22. Scope of benefits for the medically needy.

 Medically needy recipients are eligible for the family planning services listed in the MA Program fee schedule.

Source

   The provisions of this §  1225.22 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117483).

§ 1225.23. Scope of benefits for State Blind Pension recipients.

 State Blind Pension recipients are eligible for the family planning services listed in the MA Program fee schedule.

Source

   The provisions of this §  1225.23 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117483) to (117484).

§ 1225.24. Scope of benefits for General Assistance recipients.

 General Assistance recipients, age 21 to 65, whose MA benefits are funded solely by State funds, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See §  1101.31(e) (relating to scope).

Source

   The provisions of this §  1225.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION


§ 1225.41. General participation requirements.

 In addition to the participation requirements established in Chapter 1101 (relating to general provisions) and the applicable participation requirements listed in § §  1225.42, 1225.43 and 1225.45 (relating additional requirements for hospital outpatient family planning clinics; additional requirements for independent family planning clinics; and ongoing responsibilities of providers) hospital outpatient family planning clinics and independent family planning clinics shall meet the following participation requirements:

   (1)  Have a patient referral system that ensures followup treatment by other physicians or appropriate specialists.

   (2)  Be certified as a family planning clinic by the Office of Social Programs, Family Planning Division.

Cross References

   This section cited in 55 Pa. Code §  1225.42 (relating to additional requirements for hospital outpatient family planning clinics); and 55 Pa. Code §  1225.43 (relating to additional requirements for independent family planning clinics).

§ 1225.42. Additional requirements for hospital outpatient family planning clinics.

 (a)  In addition to the participation requirements listed in §  1225.41 (relating to general participation requirements) hospital outpatient family planning clinics shall meet the following participation requirements:

   (1)  Be part of an institution formally licensed as a hospital by the Department of Health.

   (2)  Be organizationally integrated with inpatient services and have the authority to independently admit patients to the hospital.

 (b)  If the hospital outpatient family planning clinic is operated indirectly through contract between the hospital and other organizations or individuals, all participation requirements of this section and §  1225.41 shall be met.

Source

   The provisions of this §  1225.42 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

Cross References

   This section cited in 55 Pa. Code §  1225.41 (relating to general participation requirements).

§ 1225.43. Additional requirements for independent family planning clinics.

 In addition to the participation requirements listed in §  1225.41 (relating to general participation requirements) independent family planning clinics shall meet the following participation requirements:

   (1)  Provide services either directly by a physician or under the supervision of a physician. This means that one or more physicians shall be on staff to either provide directly or supervise the provision of service. If a physician does not provide services directly, then:

     (i)   The services shall be provided by a certified registered nurse practitioner, a physician assistant or a registered nurse, as appropriate, on the basis of a predetermined plan of diagnosis and treatment that has been approved by a physician.

     (ii)   A physician shall be immediately available through direct communication or by radio, telephone or telecommunications.

   (2)  Not limit the number of patients served by virtue of the payment source.

   (3)  Through formal agreements, provide access to health care for emergencies related to the family planning services provided, both during and after the regularly scheduled hours of the clinic.

Source

   The provisions of this §  1225.43 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

Cross References

   This section cited in 55 Pa. Code §  1225.41 (relating to general participation requirements).

§ 1225.44. Participation requirements for out-of-State family planning clinics.

 Out-of-State family planning clinics shall meet the requirements set forth in §  1101.42(b) (relating to prerequisites for participation).

Source

   The provisions of this §  1225.44 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

§ 1225.45. Ongoing responsibilities of providers.

 Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1225.45 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

Cross References

   This section cited in 55 Pa. Code §  1225.41 (relating to general participation requirements).

PAYMENT FOR FAMILY PLANNING CLINIC SERVICES


§ 1225.51. General payment policy.

 Payment is made for services provided by or under the supervision of a physician in a hospital outpatient family planning clinic, or independent family planning clinic, subject to the conditions and limitations set forth in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.

Source

   The provisions of this §  1225.51 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117486).

§ 1225.52. Conditions of payment.

 (a)  Family planning services shall be provided either by, or under the supervision of a physician.

 (b)  Family planning services shall be provided at the clinic site.

Source

   The provisions of this §  1225.52 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

§ 1225.54. Noncompensable family planning services.

 Payment will not be made to a family planning clinic for the following services regardless of where or to whom they are provided:

   (1)  Services and procedures that are available through other public agencies, private insurance plans, and State or Federal Programs, except Titles V, X, XX, and the Indochinese Refugee Assistance Act.

   (2)  Procedures not listed in the MA Program fee schedule or the fee schedule promulgated by the Family Planning Division of the Department.

Source

   The provisions of this §  1225.54 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117486) to (117487).

UTILIZATION CONTROL


§ 1225.71. Scope of claims review procedures.

 Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1225.71 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

ADMINISTRATIVE SANCTIONS


§ 1225.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of medical practice or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1225.81 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4607.

APPENDIX A. [Reserved]



Source

   The provisions of this Appendix A reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3930. Immediately preceding text appears at serial pages (58153) to (58154).



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