NY Manual
SHP Manual

New York Provider Manual
6.3 Preventive Care Standards | 7.2 Diagnostic Testing

7. Obstetrics and Gynecology

7.1 Definition of Services

All female members have access to Obstetrician/Gynecologist (OB/GYN) care from any in-network provider without referral from their assigned PCP. An Obstetrician/Gynecologist (OB/GYN) is responsible for providing and managing medical care for obstetrical and gynecological conditions.

In addition, Medicaid members may choose to receive Family Planning and Reproductive Health services from a nonparticipating provider who accepts Medicaid for these services (also known as “Free Access Policy”). Family Planning and Reproductive Health services mean the offering, arranging, and furnishing of those health services that enable members, including minors who may be sexually active, to prevent or reduce the incidence of unwanted pregnancies. This DOES NOT include obstetrical care for pregnancy. All members, including Medicaid members, MUST use an in-network provider for obstetrical care for pregnancy.

The following medically necessary services are subject to “free access” for Medicaid female members and include related drugs and supplies that are furnished or administered under the supervision of a provider, licensed midwife, or certified nurse practitioner during the course of a Family Planning and Reproductive Health visit:

·     Family Planning and Reproductive Health services which include those education and counseling services necessary to effectively render the services
·     Contraception, including all FDA-approved birth control methods and devices, including diaphragms, insertion/removal of an intrauterine device (IUD) or insertion/removal of contraceptive implants and injection procedures involving pharmaceuticals such as Depo-Provera (FHPlus does not cover OTC products such as condoms and contraceptive foam)
·     Emergency contraception and follow-up
·     Sterilization
·     Screening, related diagnosis, and referral to a Participating Provider for pregnancy
·     Medically necessary induced abortions, which are procedures, either medical or surgical, that result in the termination of pregnancy. The determination of medical necessity shall include positive evidence of pregnancy, with an estimate of its duration

When clinically indicated, the following services may be provided as a part of a Family Planning and Reproductive Health visit:

·     Screening, related diagnosis, ambulatory treatment, and referral as needed for dysmenorrhea, cervical cancer, or other pelvic  abnormality/pathology
·     Screening, related diagnosis, and referral for anemia, cervical cancer, glycosuria, proteinuria, hypertension, and breast disease
·     Screening and treatment for sexually transmissible disease
·     HIV testing and pre- and post-test counseling

Specialty Areas under OB/GYN

Healthfirst includes the following seven (7) specialty areas in its definition of obstetrics and gynecology. Practitioners in the specialties will be referred to as OB/GYN providers in this Provider Manual unless otherwise indicated:

·     Gynecology
·     Gynecology (Nurse Practitioner)
·     Midwifery
·     Obstetrics
·     Obstetrics and Gynecology
·     Obstetrics and Gynecology (Nurse Practitioner)
·     Women’s Health (Nurse Practitioner)
·     Maternal and Fetal Medicine
·     Obstetrics and Gynecology – High-Risk

OB Provider Responsibilities

OB/GYN providers should notify Healthfirst Member Services as soon as a member’s pregnancy is confirmed. The mother’s name, member ID number, the choice of PCP for the infant, and the anticipated date of delivery should be provided. Please refer all pregnant women to the Healthfirst Obstetrical Care Management Program by calling  800-404-8778 or by faxing referrals to 1-646-313-4603. Additional information on this program is found in Section 14. 

·     Please note: OB/GYN services for pregnant, HIV-positive members must be available 24 hours a day.

PCP and OB/GYN Care

In certain circumstances, a member may choose the same provider to serve as both her PCP and OB/GYN. This might occur if a member selects a family practitioner as her PCP or HIV Specialist PCP who also provides routine OB/GYN services.

·     Healthfirst members may access OB/GYN services directly, without a referral from a PCP, for routine care. The PCP, however, may refer a member to an OB/GYN for consultation. Reports of all diagnostic tests must be forwarded to the PCP for inclusion in the member’s medical record. See Section 7.2 for additional details.