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Approval Period: April 1, 2019 through December 31, 2028 Page 10 of 28

19. Demonstration Disenrollment. If a woman becomes pregnant while enrolled in the demonstration, she may be determined eligible for Medicaid under the state plan. The state must not submit claims under the demonstration for any woman who is found to be eligible under the Medicaid state plan. In addition, women who receive a sterilization procedure and complete all necessary follow-up procedures will be disenrolled from the demonstration. Prior to the integration process described in STC 18, beneficiaries disenrolled from the demonstration due to sterilization must be provided information on how to apply for comprehensive coverage; after the integration process described in STC 18, the state must conduct a full redetermination in accordance with 42 CFR 435.916 prior to termination.

V. BENEFITS AND DELIVERY SYSTEMS

20. Family Planning Benefits. Family planning services and supplies described in section 1905(a)(4)(C) and are limited to those services and supplies whose primary purpose is family planning and which are provided in a family planning setting. As the Montana Plan First family Planning Demonstration is limited to a specific category of benefits to treat specific medical conditions, the demonstration is not recognized as Minimum Essential Coverage (MEC) consistent with the guidance set forth in the State Health Official Letter #14-002, issued by CMS on November 7, 2014. Family planning services and supplies are reimbursable at the 90 percent matching rate, including: a) Approved methods of contraception; b) Sexually transmitted infection (STI)/sexually transmitted disease (STD) testing, Pap smears and pelvic exams. The laboratory tests done during an initial family planning visit for contraception include a Pap smear, screening tests for STIs/STDs, blood count and pregnancy test. Additional screening tests may be performed depending on the method of contraception desired and the protocol established by the clinic, program or provider. Additional laboratory tests may be needed to address a family planning problem or need during an inter-periodic family planning visit for contraception; c) Drugs, supplies, or devices related to women’s health services described above that are prescribed by a health care provider who meets the state’s provider enrollment requirements (subject to the national drug rebate program requirements); and d) Contraceptive management, patient education, and counseling.

21. Family Planning-Related Benefits. Family planning-related services and supplies are defined as those services provided as part of or as follow-up to a family planning visit and are reimbursable at the state’s regular Federal Medical Assistance Percentage (FMAP) rate. Such services are provided because a “family planning-related” problem was identified and/or diagnosed during a routine or periodic family planning visit. Examples of family planning-related services and supplies include: a) Colposcopy (and procedures done with/during a colposcopy) or repeat Pap smear performed as a follow-up to an abnormal Pap smear which is done as part of a routine/periodic family planning visit. b) Drugs for the treatment of STIs/STDs, except for HIV/AIDS and hepatitis, follow-up visit/encounter for the treatment/drugs and subsequent follow-up visits to rescreen for