TMPPM 2008 > Texas Medicaid Services > Physician > Procedures and Services

36.4.11 Elective Sterilization Services

The Texas Medicaid Program benefits include payment for elective sterilization (performed solely for the purpose of rendering the individual incapable of bearing or fathering children) of eligible clients when providers comply with HHS regulations (42 Code of Federal Regulations [CFR] 441.250, Subpart F).

Refer to: Section 19.3.3 "Sterilization Consent Form and Instructions" for further information.

Payment of elective sterilization is not made if the client meets any of the following criteria:

•Is younger than 21 years of age at the time the consent form is signed.

•Has been declared mentally incompetent for the purpose of sterilization (clients are presumed to be mentally competent unless adjudicated incompetent for the purpose of sterilization).

•Is institutionalized in a correctional facility, mental hospital, or other rehabilitative facility.

•Gave consent in labor or childbirth, under the influence of alcohol or other drugs, or while seeking or obtaining an abortion.

Note: All Medicaid clients, electing sterilization services including those in a STAR or STAR+PLUS Program health plan, must sign a Sterilization Consent Form. The form must be submitted to the client's health plan.

TMHP must have a signed, valid Sterilization Consent Form on file to reimburse an elective sterilization procedure. Typewritten, blocked, or facsimile stamped signatures are not acceptable for signature requirements. When a valid consent form is received by TMHP, the Medicaid client's eligibility file is updated to reflect receipt. Subsequent claims received by TMHP for the sterilization covered by the consent are referenced to the valid consent and reimbursed even if they are not accompanied by a valid consent. It is to the provider's benefit to submit a consent form with claims for sterilization rather than relying on a fellow provider. A legible, valid copy of the consent is acceptable.

Providers may copy onto their letterhead the Sterilization Consent Form. Providers may use their own consent form as long as the form has the HHS-approved language and required fields. Providers who want their own consent form must obtain approval from HHS.

A mechanism for processing Sterilization Consent Forms aimed at reducing the number of unnecessary denials for sterilization covered under family planning and billed to Medicaid is used by TMHP. Family planning providers may provide sterilization to their clients after a waiting period of 30 days, defined as 30 full 24-hour periods from the time in which formal consent was obtained from the client. The waiting period prevents the denial of sterilization claims for sterilization conducted on the 30th day, despite the fact that 30 full days (24-hour periods) passed from the time of written consent.

When a sterilization is performed at the time of a premature delivery, the time of the client's consent must be at least 72 hours before the actual delivery and 30 days before the expected date of delivery. (The consent form is valid for 180 days from the date of the client's signature.) If emergency abdominal surgery occurs, the time of the client's consent must be at least 72 hours before surgery.

These instructions must be followed when completing the HHS-approved consent form. All blanks should be completed unless otherwise specified.

•The client's nine-digit Medicaid number must be recorded in the blocks provided at the top of page 1.

•The first section of the consent form, Consent to Sterilization, must be completed in English or Spanish.

•The Race and Ethnicity Designation is optional.

•An interpreter must be provided if the consent form is not written in the language of the individual to be sterilized or the person obtaining consent does not speak the individual's language. If an interpreter is used, the Interpreter's Statement must be completed.

•The Statement of the Person Obtaining Consent must be completed by the person who explains the surgery and its implications, alternate methods of birth control, and the fact that the consent may be withdrawn at any time. The signature of the person obtaining consent must be completed at the time the consent is obtained. The signature must be an original signature, not a rubber stamp.

•The physician or the person obtaining consent must allow a witness of the client's choice (if desired) when the consent form is signed, and arrangements must be made for individuals with disabilities.

•The Physician's Statement must be completed. The physician must indicate that 30 days or 72 hours have passed between consent and surgery by crossing out paragraph number 1 or 2 as indicated on the consent form.

•The Physician's Statement must be signed and dated on or after the day of surgery in all circumstances. The signature must be an original signature, not a rubber stamp.

•When the sterilization is performed at the time of a premature delivery, the expected date of delivery must be recorded in the space provided on the consent form and must be 30 days from date of client's signature.

•When the sterilization is performed at the time of emergency abdominal surgery, the circumstances must be described in the space provided on the consent form. If the space is not sufficient, additional documentation may be attached to the consent form.

•The physician must review the consent form with the client shortly before surgery.

•The actual sterilization procedure performed must be identical to that for which the client gave informed, written consent. Each reference to the sterilization procedure on the consent form and the claim form (for example, salpingectomy cannot be interchanged with tubal ligation) must be identical.

•Sterilization Consent forms may be faxed to 1-512-514-4229. Follow the guidelines under "Faxing Forms" .

Refer to: "Sterilization Consent Form Instructions (2 Pages)".

"Sterilization Consent Form (English)".