Contraceptive Services

In accordance with state law, most HMSA plans cover contraceptive services and supplies.

Plans that Do Not Currently Provide Contraceptive Benefits

• HMSA and HPH individual and conversion plans (e.g., Plan 6)
• Plans sponsored by religious employers that have made a decision to exempt themselves

To verify whether contraceptive services is a benefit of your patient’s plan, please refer to HHIN+ or call a Provider Services representative and inform them of your patient’s HMSA membership ID number and coverage code number.

Contraceptive Coverage Safe Harbor

The Affordable Care Act (ACA) requires non-grandfathered plans to offer women’s preventive health screening services, including contraceptives, without a copayment for all plan years beginning on or after Aug. 1, 2012. Plans maintained by certain religious employers may be exempt from the contraceptive provision. A new safe harbor ruling allows non-grandfathered plans that do not qualify for this exemption to delay offering contraceptives without a copayment for one year (i.e., for all plan years beginning on or after Aug. 1, 2013) if the plans certify and document that they meet the following requirements:

• The organization that established or maintains the plan is a non-profit.
• From Feb. 10, 2012 onward, the plan has consistently not provided all or the same subset of the contraceptive coverage otherwise required because of the religious beliefs of the organization that established or maintains the plan.
• The plan provides notice to members that some or all contraceptive coverage will not be provided for the first plan year beginning on or after Aug. 1, 2012.

To check if services are covered by a member’s plan, go to hhinplus.hmsa.com or call 808-948-6330 on Oahu or 1-800-790-4672 toll-free on the Neighbor islands.

Covered Services

Professional services

• Office visits may be billed separately when contraceptive services are not administered during the visit (e.g., family planning counseling). Payment will be made based on regular plan benefits for office visits.
• Insertion and removal of implants
• Insertion and removal of IUDs
• Administration of contraceptive injections
• Fitting of a diaphragm or cervical cap

Devices, Drugs and Supplies

For those HMSA plans that provide coverage for contraceptive services and supplies, HMSA covers the following:

• Oral contraceptives – HMSA covers oral contraceptives: Refer to HMSA’s formulary to identify if a specific contraceptive is covered. HMSA will cover oral contraceptives other than those listed above only if: (1) the use of the above covered brands has resulted in an adverse drug reaction; or (2) the member has not used the above brands, but, based on the member’s past medical history, the prescribing healthcare practitioner believes that using the covered brands would result in an adverse drug reaction based on the member’s medical history.
  • These items will be covered under the member’s drug rider. Members who have medical coverage only also qualify for the oral contraceptives which may be obtained at a pharmacy.
• Diaphragms and cervical caps – one device per year. These items will be covered under the member’s drug rider. Members who have medical coverage only also qualify for the devices. They may be obtained at a pharmacy and will be processed through HMSA’s online claims processing system.
• Implantable contraceptives – limited to one implant per period of effectiveness (e.g., for Implanon, the period of effectiveness is three years).
• Injectable contraceptives – limited to one injection per period of effectiveness (e.g., Depo-Provera is covered for four injections per calendar year).
• IUDs – limited to one IUD per period of effectiveness.

Note: Contraceptive devices or supplies do not count toward any annual copayment maximums or deductibles. Coverage is only for contraceptive devices or supplies that are FDA approved and require a prescription. For example, condoms and contraceptive foam, available over the counter, are not covered.

Claims Filing Instructions

Office visits

Physicians may bill for a contraceptive management visit using the following office visit codes:

• CPT codes 99211 - 99215
• CPT codes 99201 - 99205

Note: If contraceptive management is done incidental to an annual well-woman exam, only the well-woman exam should be billed using HCPCS code S0610, S0612 or S0613. (See Well-Woman Exam.)

Physicians may bill for the following contraceptive methods:

Contraceptive implants (e.g., Implanon)

Notes: Benefits may vary depending on the specific plan coverage code. Benefits are generally reflected as a percentage of HMSA’s eligible charge or dollar copayment. To verify the copayment amount a member owes, please check the Hawaii Healthcare Information Network (HHIN+), or Plan Documents, or call Provider Services.

For grandfathered plans, copayments for insertion and removal are paid based on plan benefits for surgery.

Coverage for the implants includes payment for an annual office visit/evaluation. This service should not be billed separately.

Intrauterine devices (IUDs)

Notes: Benefits may vary depending on the specific plan coverage code. Benefits are generally reflected as a percentage of HMSA’s eligible charge or dollar copayment. To verify the copayment amount a member owes, please check the Hawaii Healthcare Information Network (HHIN+) or Plan Documents, or call Provider Services.

The device is eligible for coverage once per 12 calendar months. Coverage for insertion and removal of the device includes payment for an annual office visit/evaluation. The office visit should not be billed separately.

Injectables (e.g., Depo-Provera)

Notes: Benefits may vary depending on the specific plan coverage code. Benefits are generally reflected as a percentage of HMSA’s eligible charge or dollar copayment. To verify the copayment amount a member owes, please check the Hawaii Healthcare Information Network (HHIN+) or Plan Documents, or call Provider Services.

Depo-Provera’s contraceptive dosage is 150 mg, administered by an obstetrician or gynecologist every three months.

An office visit may be billed separately from the initial injection. The administration of the injection is included in HMSA's payment for the office visit and should not be billed separately.

Office visits should not be billed with subsequent injections. Subsequent injections should include the charge for the injectable medication. A separate charge for the administration of the injection (CPT 96372) may also be billed.

Diaphragms/cervical caps

Revision History