DHS 107.21(1)(b)1.
1. Complete obstetrical history including menarche, menstrual, gravidity, parity, pregnancy outcomes and complications of pregnancy or delivery, and abortion history;
DHS 107.21(1)(b)2.
2. History of significant illness-morbidity, hospitalization and previous medical care, particularly in relation to thromboembolic disease, any breast or genital neoplasm, any diabetic or prediabetic condition, cephalalgia and migraine, pelvic inflammatory disease, gynecologic disease and venereal disease;
DHS 107.21(1)(b)4.
4. Family, social, physical health, and mental health history, including chronic illnesses, genetic aberrations and mental depression;
DHS 107.21(1)(c)
(c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:
DHS 107.21(1)(c)1.d.
d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and
DHS 107.21(1)(c)2.g.
g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;
DHS 107.21(1)(c)3.
3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;
DHS 107.21(1)(c)5.
5. Colposcopy, culdoscopy, and laparoscopy procedures which may be either diagnostic or treatment procedures.
DHS 107.21(1)(d)
(d) Counseling services. Counseling services in the clinic are covered as indicated in this paragraph. These services may be performed or supervised by a physician, registered nurse or licensed practical nurse. Counseling services may be provided as a result of request by a recipient or when indicated by exam procedures and health history. These services are limited to the following areas of concern:
DHS 107.21(1)(d)2.
2. Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each shall be provided;
DHS 107.21(1)(d)4.
4. Counseling about sterilization accompanied by a full explanation of sterilization procedures including associated discomfort and risks, benefits, and irreversibility;
DHS 107.21(1)(d)5.
5. Genetic counseling accompanied by a full explanation of procedures utilized in genetic assessment, including information regarding the medical ramifications for unborn children and planning of care for unborn children with either diagnosed or possible genetic abnormalities;
DHS 107.21(1)(d)7.
7. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
DHS 107.21(1)(e)
(e) Contraceptive methods. Procedures related to the prescription of a contraceptive method are covered services. The contraceptive method selected shall be the choice of the recipient, based on full information, except when in conflict with sound medical practice. The following procedures are covered:
DHS 107.21(1)(e)1.b.
b. Localization procedures limited to sonography, and up to 2 x-rays with interpretation;
DHS 107.21(1)(e)3.b.
b. A follow-up office visit once during the first 90 days after the initial prescription to assess physiological changes. This visit shall include taking blood pressure and weight, interim history and laboratory examinations as necessary.
DHS 107.21(1)(f)
(f) Office visits. Follow-up office visits performed by either a nurse or a physician and an annual physical exam and health history are covered services.
DHS 107.21(1)(g)
(g) Supplies. The following supplies are covered when prescribed:
DHS 107.21(2)
(2)
Services requiring prior authorization. All sterilization procedures require prior authorization by the medical consultant to the department, as well as the informed consent of the recipient. Informed consent requests shall be in accordance with s.
DHS 107.06 (3).
DHS 107.21 Note
Note: For more information on prior authorization, see DHS 107.02 (3).
DHS 107.21(3)
(3)
Non-covered services. The following services are not covered services:
DHS 107.21(3)(a)
(a) The sterilization of a recipient under the age of 21 or of a recipient declared legally incapable of consenting to such a procedure;
DHS 107.21(3)(b)
(b) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to:
DHS 107.21(3)(b)1.
1. Artificial insemination, including but not limited to intra-cervical or intra-uterine insemination;
DHS 107.21(3)(b)3.
3. Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;
DHS 107.21(3)(b)4.
4. Reversal of female sterilizations, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;
DHS 107.21(3)(b)5.
5. Fertility-enhancing drugs provided for the treatment of infertility;
DHS 107.21(3)(b)7.
7. Office visits, consultations and other encounters to enhance fertility; and
DHS 107.21(3)(c)
(c) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services;
DHS 107.21 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.21 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) (c) 3., (3), r. (1) (d) 4., renum. (1) (d) 5. to 8. to be (1) (d) 4. to 7;
Register, January, 1997, No. 493, eff. 2-1-97.
DHS 107.22
DHS 107.22 Early and periodic screening, diagnosis and treatment (EPSDT) services.
