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TO:  All Family Planning Providers (Physicians, FQHC, IRHC, PBRHC), Hospitals, Obstetricians-Gynecologists, and Plan First Providers

Vasectomies have been a Medicaid covered service for men age 21 or older who have full Medicaid benefits for several years.  Effective August 1, 2015, and thereafter, the Alabama Medicaid Agency (Medicaid) will begin coverage of vasectomies for men age 21 or older who are eligible for the Plan First program.

All men receiving a vasectomy under the Plan First Program are required to have a completed Alabama Medicaid Agency Sterilization Consent Form (Form 193) prior to the surgery.  The Sterilization Consent Form must be completed in accordance with the guidelines outlined in the Alabama Medicaid Agency Provider Manual, Appendix C located on Medicaid’s website at http://www.medicaid.alabama.gov/CONTENT/6.0_Providers/6.7_Manuals.aspx.

A copy of the Sterilization Consent Form can be found in Medicaid’s Form Library by accessing the following link:   http://medicaid.alabama.gov/documents/5.0_Resources/5.4_Forms_Library/5.4.1_Billing/
5.4.1_Consent_Sterilization_Form193_2-10-10.pdf.

The date of signed informed consent and the date of the sterilization procedure must be at least 30 days apart, but not more than 180 days apart.

Providers that perform only vasectomies, including surgeons and anesthesiologists, do not have to enroll as Plan First providers. It is the responsibility of the performing surgeon to submit a legible completed copy of the Sterilization Consent Form after the surgery to Medicaid’s Fiscal Agent, Hewlett-Packard Enterprise Services (HPES). The completed Sterilization Consent Form should be mailed to HPES at the following address:

Attn: Medical Policy Unit/Consent Forms

For additional information regarding proper billing procedures, reference the ALERT dated July 23, 2015 entitled, Coverage of Vasectomies under the Plan First Program located on Medicaid’s website. 

For questions regarding this ALERT, contact Ruth Harris, Program Manager, Plan First Program at 334-353-3562 or via email at ruth.harris@medicaid.alabama.gov.