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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook : 3. Women’s Health Program (Title XIX Family Planning) : 3.3 Services, Benefits, Limitations, and Prior Authorization : 3.3.9 WHP Client Eligibility

After the sterilization and all related services have been completed, the client is no longer eligible for WHP services and should disenroll from the program. Clients who have been sterilized cannot enroll in the WHP unless they are seeking to have the sterilization confirmed. Clients may enroll in the WHP to confirm the sterilization, but must disenroll afterwards.
Providers must inform WHP clients who seek sterilization that, after the sterilization procedure, the WHP covers only the follow-up visit to confirm the sterilization and the short-term contraceptives that are dispensed for the 12-week period following the insertion of an occlusive sterilization system.
A client who has been approved for WHP coverage remains enrolled in the program for 12 continuous months even if a sterilization procedure has been performed during the 12-months of coverage. After sterilization has been confirmed, a client is not eligible to renew WHP coverage.
After an occlusive sterilization procedure, if the client’s 12-month WHP coverage lapses before the sterilization is confirmed, the client may reapply for coverage in order to access short-term contraceptives and the hysterosalpingography necessary to confirm that the fallopian tubes are blocked. If it has not been confirmed that the occlusive sterilization system is blocking the fallopian tubes, the client is not considered to have been sterilized.
A WHP client can be disenrolled from the program before the 12-month term ends only in the following cases:
The client becomes eligible for full Medicaid, the Children’s Health Insurance Program (CHIP), or another publicly-funded health coverage program that is more comprehensive than WHP.
If it is discovered during the visit that the client has received a surgical or nonsurgical sterilization procedure before enrolling with the WHP, but the client did not indicate that information on the WHP application (e.g., because she filled out the WHP application incorrectly, she misunderstood the question), the provider should:
If a provider suspects that a WHP client has committed fraud on the application, the provider should report the client to the Health and Human Services (HHSC) Office of Inspector General (OIG) at 1‑800‑436-6184.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.