PA Medicaid: Updated reproductive health services guidance

The Commonwealth Court of Pennsylvania recently ruled that the state’s limited coverage of abortion services under the Abortion Control Act is unconstitutional. 

Under the ruling, the Pennsylvania Department of Human Services (DHS) would need to cover medically necessary abortion services, the limited abortion services outlined in the Abortion Control Act and those that don’t qualify for federal funding. These additional services must be paid for entirely by the state.

To prepare for potential implementation, DHS issued guidance to Physical Health Managed Care Organizations outlining billing and reporting requirements for federally-funded and state-funded services.

This expanded coverage won’t go into effect until the Pennsylvania Supreme Court instructs DHS to implement the Commonwealth Court’s decision. We’ll provide updated information as it becomes available.

What to do next

Until the decision is implemented, providers should continue to follow current requirements for abortion services that qualify for federal Medicaid funding and retain the MA-3 form, or an equivalent form containing the same information, to support federally-funded services.

Medically necessary abortion services that qualify for federal funding are those that are performed only when continuing the pregnancy would endanger the mother’s life, or the pregnancy is the result of rape or incest.

Remember to submit eligible procedure codes with the appropriate modifier. The modifiers are U1 (mother’s life endangered), U2 (rape or incest) and U4 (miscarriage).