Fillable Printable Form 411

Form 411

CHAPTER 400

MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH

POLICY 411

WOMEN’S PREVENTATIVE CARE SERVICES

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 411-1

AHCCCS MEDICAL POLICY MANUAL

411 WOMEN’S PREVENTATIVE CARE SERVICES

INITIAL

EFFECTIVE DATE: 10/01/2015

Description

An annual well-woman preventative care visit is a covered benefit for women to obtain the

recommended preventive services, including preconception counseling.

Amount, Duration and Scope

A well-woman preventative care visit is covered on an annual basis when clinically

indicated.

A. WELL-WOMAN PREVENTATIVE CARE SERVICES DEFINITIONS

1. Human Papillovirus (HPV) - A sexually transmitted infection for which a series

of immunizations are available for both males and females beginning at a

recommen ded age o f 11 years up to 26 years of age. Refer to AMPM Policy 310-

M, Immunizations for further information related to immunization coverage.

2. Family Planning Counseling - The provision of accurate information and

discussion with a health care provider to allow members to make informed

decisions about the specific famil y planning methods available that ali gn with the

member’s lifestyle.

3. Mammogram - An x-ray of the breast used to look for early signs of breast cancer.

Coverage does not include genetic testing.

4. Clinical Breast Exam - A physical examination of the breasts by a health care

provider used as a primary diagnostic procedure for early detection of breast

cancer.

5. Preconception Counseling – Counseling aimed at identifying/reducing behavioral

and social risks, through preventive and management interventions, in women of

reproductive age who are capable of becoming pregnant, regardless of whether

she is planning to conceive. This counseling focuses on the early detection and

management of risk factors before pregnancy and includes efforts to influence

behaviors that can affect a fetus prior to conception The purpose of

preconception counseling is to ensure that a woman is healthy prior to pregnancy.

NOTE: Preconception counseling is considered included in the well-woman

preventative care visit and does not include genetic testing.

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MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH

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WOMEN’S PREVENTATIVE CARE SERVICES

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 411-2

AHCCCS MEDICAL POLICY MANUAL

6. Well Exam - A physical examination in the absence of any known disease,

symptom, or specific medical complaint by the member precipitating the

examination.

B. CONTRACTOR REQUIREMENTS FOR WELL-WOMAN PREVENTATIVE CARE

SERVICES

Contractors must develop policies and procedures to monitor, evaluate, and improve

women’s participation in preventative care services.

Contractors must:

1. Inform all participating Primary Care Providers (PCPs) and Obstetrician/

Gynecologist (OB/GYN) providers of the availability of women’s preventative

care services, detailing the covered services included as part of the well-woman

preventative care visit, as outlined in Section C-1 of this policy.

2. Develop and implement a process for monitoring compliance with well-woman

preventative care services provider requirements.

3. Develop, implement, and maintain a process to inform members about women’s

preventative health services annually and within 30 days of enrollment with the

Contractor for newly enrolled members. This information must be provided in a

second language, in addition to English, in accordance with the requirements of

the AHCCCS Division of Health Care Management (DHCM) “Cultural

Competency” policy available in the AHCCCS Contractor Operations Manual

(available online at http://www.azahcccs.gov/shared/ACOM/default.aspx).

a. This information must include:

i. The benefits of preventive health care,

ii. A complete description of the services available as described in this

section,

iii. Information on how to obtain these services. This must include a statement

that assistance with medically necessary transportation and scheduling

appointments is available to obtain well-woman preventative care

services, and

iv. A statement that there is no copayment or other charge for women’s

preventative care visit.

C. WELL-WOMAN PREVENTATIVE CARE SERVICES PROVIDER REQUIREMENTS

Provider requirements for well-woman preventative care services include the

following:

1. Covered Services Included as Part of a Well-Woman Preventative Care Visit An

annual wel l -woman preventative care visit is intended for the identification of risk

factors for disease, identification of existing medical/mental health problems, and

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MEDICAL POLICY F OR MATERN AL AND CHILD HEALTH

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WOMEN’S PREVENTATIVE CARE SERVICES

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 411-3

AHCCCS MEDICAL POLICY MANUAL

promotion of healthy lifestyle habits essential to reducing or preventing risk

factors for various disease processes. As such, the well-woman preventative care

visit is inclusive of a minimum of the following:

a. A physical exam (well exam) that assesses overall health.

b. Clinical breast exam.

c. Pelvic exam (as necessary, according to current recommendations and best

standards of practice).

d. Review and administration of immunizations, screenings and testing as

appropriate for age and risk factors. Refer to AMPM 310-H, Health Risk

Assessment and Screening Tests for further information pertaining to health

risk assessments and associated screening tests.

NOTE: Genetic screening and testing is not covered, except as described in

AMPM Chapter 300, Medical Policy for Covered Services.

e. Screening and counseling is included as part of the well-woman preventive

care visit and is focused on maintaining a healthy lifestyle and minimizing

health risks, that addresses at a minimum the following:

i. Proper nutrition

ii. Physical activity

iii. Elevated BMI indicative of obesity

iv. Tobacco/substance use, abuse, and/or dependency

v. Depression screening

vi. Interpersonal and domestic violence screening, that includes counseling

involving elicitation of information from women and adolescents about

current/past violence and abuse, in a culturally sensitive and supportive

manner to address current health concerns about safety and other current

or future health problems

vii. Sexually transmitted infections

viii. Human Immunodeficiency Virus (HIV)

ix. Family planning counseling

x. Preconception counseling that includes discussion regarding a healthy

lifestyle before and between pregnancies that includes:

(a) Reproductive history and sexual practices

(b) Healthy weight, including diet and nutrition, as well as the use of

nutritional supplements and folic acid intake

(d) Oral health care

(e) Chronic disease management

(f) Emotional wellness

(g) Tobacco and substance use (caffeine, alcohol, marijuana and other

drugs), including prescription drug use

(h) Recommended intervals between pregnancies

NOTE: Preconception counseling does not include genetic testing.

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AHCCCS MEDICAL POLICY MANUAL

f. Initiation of necessary referrals when the need for further evaluation,

diagnosis, and/or treatment is identified.

2. Well-Woman Preventative Care Service Standards

Immunizations - AHCCCS will cover the Human Papilloma Virus (HPV)

vaccine for female members 11 to 26 years of age. For adult immunizations, refer

to Policy 310-M, Immunizations. Providers must coordinate with The Arizona

Departmen t of H ealth Se rvices (ADHS) V accines fo r Children (VFC) Pro gram in

the delivery of immunization services if providing vaccinations to Early and

Periodic Screening, Diagnostic and Treatment (EPSDT) aged members less than

19 years of age. Immunizations must be provided according to the Advisory

Committee on Immunization Practices Recommended Schedule. (Refer to the

CDC website at http://www.cdc.gov/vaccines/schedules/index.html where this

information is included). Providers must enroll and re-enroll annually with the

VFC program, in accordance with AHCCCS contract requirements in providing

immunizations for EPSDT aged members less than 19 years of age, and must

document each EPSDT age member’s immunizations in the Arizona State

Immunization Information System (ASIIS) registry. In addition, the Contractor

shall not utilize AHCCCS funding to purchase va ccines covered through the VFC

program for members younger than 19 years of age.

Screenings - Refer to AMPM Policy 310-H, Health Risk Assessment and

Screening Tests for further details pertaining to specific screening and limitations

related to health risk assessments and associated screening tests for those

members over 21 years of age. Refer to AMPM Policy 430, EPSDT Services for

further details related to covered services for members less than 21 years of age.

D. ADDITIONAL COVERED RELATED SERVICES

Refer to AMPM Policy 310-H, Health Risk Assessment and Screening Tests for further

details pertaining to specific screening and limitations related to health risk assessments

and associated screening tests.

Refer to AMPM Policy 420, Family Planning for further details related to the family

planning covered services.