1. (A) For an initial or annual visit, a family planning agency must provide all of the following medical and laboratory services:

   1. (1) a complete medical history (including family and interval);

   2. (2) a physical examination:

      1. (a) for a member who is female, this includes thyroid, breast, heart, abdominal, speculum, pelvic, and rectal examinations, and measurements of height, weight, and blood pressure;
      2. (b) for a member who is male, this includes thyroid, heart, genital, abdominal, and rectal examinations, and measurements of height, weight, and blood pressure;
   3. (3) a Pap smear (for a female member) as indicated by current nationally recommended protocols, such as American College of Obstetrics and Gynecology (ACOG), American Cancer Society (ACS), or the US Preventive Services Task Force (USPSTF);
   4. (4) any laboratory test indicated by the member's history or examination (such a test may be provided directly or by referral);
   5. (5) a medically approved method of contraception, if appropriate; and
   6. (6) referrals for the screening, diagnosis, prevention, or treatment of general as well as reproductive medical conditions.

2. (B) For a routine visit, a family planning agency must provide medical and laboratory services necessary to monitor the member's contraceptive care or to follow-up on conditions requiring medical attention by agency personnel. These services must include, but are not limited to, the following:

   1. (1) update of medical history;
   2. (2) a physical examination that may include pelvic or genital examination;
   3. (3) measurements of blood pressure and weight;
   4. (4) any laboratory test indicated by the member's history or examination (such a test may be provided directly or by referral);
   5. (5) identification of any symptoms, conditions, or side effects that may contraindicate the method of contraception used;
   6. (6) assessment of the member's use of the method of contraception; and
   7. (7) referrals for the screening, diagnosis, prevention, or treatment of general as well as reproductive medical conditions.
3. (C) For a minimal visit, a family planning agency must provide counseling services only or brief medical and counseling services. The purpose of a minimal service visit is to reinforce contraceptive instructions, to monitor the member’s use of a contraceptive method, or to provide education and counseling.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Division of Medical Assistance 4 PROGRAM REGULATIONS

4-5

Provider Manual Series (130 CMR 421.000) FAMILY PLANNING AGENCY TRANSMITTAL LETTER DATE

MANUAL

FPA-39 11/01/05

1. (D) A family planning agency must make available all methods of contraception listed in Subchapter 6 of the Family Planning Agency Manual.
2. (E) Physical examinations must be performed by a physician, a nurse practitioner, or a physician assistant. A physician must examine all members with medical problems and members who request to be seen by a physician. A nurse practitioner or physician assistant may examine members during an initial, annual, or routine visit. A physician must be on site or on call during all hours of operation.
3. (F) The family planning agency must have written medical protocols that include a periodicity schedule for return visits, procedures for follow-up for each method of contraception, procedures for care of high-risk patients, and emergency drug protocols.