This is a collection of questions about providing family planning services during the COVID-19 pandemic with corresponding evidence-based answers and the current advice at this time. Family planning providers should use the Interim CDC Guidance on Handling Non-COVID-19 Public Health Activities to plan for services. Beyond continuing to provide accessible, high-quality, client-centered family planning services, the overriding objective in providing answers to these questions is to promote physical distancing; that is, keeping in-person visits to a minimum to protect both clinic staff and clients from becoming infected with SARS-CoV-2 virus and acquiring COVID-19 infection. Since the mitigation strategies recommended by CDC guidance includes limiting face-to-face interactions to only the most essential, this document assumes that clinics will have converted most or all client interactions from in-person visits to virtual visits, and utilizing curbside pick-up or mail to deliver contraceptives and other supplies.
Most of the references cited here were published before March, 2020, and therefore do not provide specific advice regarding how certain practices can be modified or deleted in response to this public health emergency. Family planning providers should use this information to develop or modify their local clinic protocols, ideally including clinical staff members who will be providing client care, remotely or in-person. In some cases, clinic staff will have to balance the benefit of physical distancing against the potential risk of adopting less traditional approaches to care. It is important to keep in mind that some of these modifications will be temporary and will be reversed once the public health emergency is no longer present, while others may remain and change practice for the better.
The questions and answers have been categorized in the same format as Providing Quality Family Planning Services: Recommendations of the CDC and the U.S. Office of Population Affairs (OPA). FPNTC will update this resource frequently to address additional questions as more information becomes available and public health priorities evolve during the pandemic. Please send questions to firstname.lastname@example.org. Title X grantees should consult with their OPA Project Officer to ensure practice modifications comply with Federal regulations.
Combined hormonal contraceptives, progestin-only pills
How can family planning providers obtain blood pressure (BP) when the provider is offsite?
BP measurement is necessary because hypertension is one of five risk factors for acute myocardial infarction (heart attack) in women using estrogen-containing hormonal methods (the other four are older age, heavy smoking, diabetes, and abnormal lipid levels [low HDL, high LDL, or high triglycerides]). If a client has more than one risk factor, the risk of a heart attack increases with each. For combined hormonal contraception (CHC)—including oral contraceptives (OC), patch, ring—The U.S. Medical Eligibility Criteria for Contraceptive Use (MEC) classifies multiple risk factors for atherosclerotic cardiovascular disease as MEC Category 3/4, depending on the individual client’s history. In addition, severe hypertension (systolic >160 mmHg or diastolic >100 mg Hg) or hypertension with vascular disease are MEC Category 4.
The U.S. Selected Practice Recommendations for Contraceptive Use (SPR) states that BP “should be measured before initiation of CHCs. In instances in which BP cannot be measured by a provider, BP measured in other settings can be reported by the woman to her provider” (p. 24). Subsequently, at the time of other routine follow-up visits, assessment of BP is recommended, but again the SPR states that “BP measurement in other settings is acceptable” (p. 27). Other settings may include BP measured on a home monitor or using a BP machine at a local pharmacy.
If a client has a recorded normal BP in the system’s electronic medical record in any clinical setting (for instance if they saw a provider for a different reason), that reading can be used. The current USPSTF recommendation is: “Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years,” which provides an outer time limit for use of the last BP reading.
Some clinics have implemented a policy whereby if a client wants to start a CHC and has no cardiovascular risk factors, she can be given a prescription (or supplies for curb-side pick-up) of 3 cycles of OCs, patch or ring, postponing an in-person BP measurement until after the public health emergency has ended. Others have developed the ability to have the client drive to the clinic parking lot, be given a home BP machine with a recordable read-out to be used in their car, then returned to staff using appropriate PPE.
Finally, if it is not possible to get a BP reading, consider offering the client a non-estrogen-containing contraceptive method until the client’s BP can be measured and documented.
For a client with documented normal BP within the last 3-5 years and no other cardiovascular disease risk factors, do all or a majority of BP readings have to be within normal limits?
While there are no specific guidelines about this, the most important consideration is whether the most recent BP reading(s) were in the normal range.
Some of our clients may not be able to afford to pay for contraceptives at the pharmacy. What are strategies we can use to assist clients with this?
Title X providers should use the same strategies that have been used prior to the public health emergency (for example, stocking of methods using 340B pricing and distribution directly from Title X-funded family planning sites) to minimize cost as a barrier for clients. Curbside pickup or mailing of supplies and medications is encouraged by OPA. As a reminder, clients should be charged according to the sliding fee requirements of Title X (i.e. clients at or below 100% of the federal poverty level must not be charged; clients between 101% and 250% must be charged a discounted rate based on the client’s ability to pay; and clients over 250% should be charged fair market value.)
What options can family planning providers offer clients who are due for their depot medroxyprogesterone acetate (DMPA) shot to avoid a clinic visit?
DMPA can be administered in two ways: intramuscularly (IM) 150 mg or subcutaneously (-SQ or sub-Q) 104 mg. They are equally effective, with a typical use failure rate of 4 pregnancies per 100 women per year. DMPA 150 IM is available in both brand name and generic versions; DMPA-SQ is available only as a brand name product (depo-subQ provera 104®).
According to SPR, DMPA is given every 13 weeks but is effective for up to 15 weeks. If DMPA 150mg IM injections are not available in-person or as a curbside service (with the client being injected while in her car), she can either get a prescription for another method until restarting DMPA 150mg IM or consider switching to the self-injected DMPA-SQ.
DMPA-SC 104 is a good choice for clients who are experienced in self-injection (e.g., fertility drugs to induce ovulation, insulin, or a drug for multiple sclerosis) or who are willing to learn how to self-inject this product. It can be used by clients who currently receive DMPA 150 mg IM every 13 weeks who want to switch to this delivery route or can be used by clients new to DMPA.
While depo-subQ provera 104 is not FDA-labeled for self-injection, studies have demonstrated the safety and feasibility of self-administered DMPA SQ.1,2, Given current FDA labeling states that "Depo-subQ provera 104 is only for subcutaneous administration and is only to be administered by a healthcare professional," prescribing it to a client for self-injection is an “off-label” use. Providers should use their clinical judgement to determine whether this method of delivery is appropriate for the client, and should document their rationale.
How can family planning providers train clients for DMPA-SQ injections? Does it have to be by telemedicine?
Ideally, clients who initiate this method should receive instruction in the self-injection technique by a synchronous audio/video telehealth visit. If this is not possible, the client should be referred to a training resource for step-by-step instruction. Example training resources include:
- Detailed package insert instructions
- Bedsider.org: Depo SubQ: The do-it-yourself birth control shot
- Reproductive Health Access Project: Depo-Provera Sub-Q User Guide (available in English, Spanish, Simplified Chinese, Traditional Chinese, Hindi, Vietnamese)
Can family planning providers order DMPA-subQ 104 to a local pharmacy?
Yes. Many pharmacy chains list DMPA-SQ as an available product. However, call the pharmacy in advance to find out if it is in stock, and if not, how long it will take the pharmacy to make it available. Always check to see if this product is on the formulary of the client’s health plan. If not, full price out-of-pocket costs with programs such as GoodRx.com is about $250.00. Some pharmacies will mail or deliver the product to the client’s home or offer curbside pick-up.
Are there any specific recommendations for how to maximize safety while giving injections?
Family planning providers should use the Interim CDC Guidance to make decisions about face-to-face activities depending on the local level of community transmission or impact of COVID-19. In accordance with CDC guidance, both staff and clients should wear a mask when providing services in close proximity. Staff should use “medical-grade” face masks (a N-95 or specialized respirator if there is very close proximity to droplets) and follow all universal precautions protocols such as wearing gloves, disposing of sharps safely, and cleaning rooms and equipment between clients. Clients may wear cloth face masks but staff should not rely on them.
1 Dragoman MV, Gaffield ME. The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review. Contraception. 2016 Sep; 94(3):202–15.
2 Beasley A, White KO, Cremers S, Westhoff C. Randomized clinical trial of self-versus clinical administration of subcutaneous depot medroxyprogesterone acetate. Contraception. 2014 May; 89(5):352–6.
IUDs and Implants
Can family planning providers still safely provide intrauterine devices (IUD) and implants?
Yes, some family planning providers are continuing to offer IUDs and implants to meet clients’ pregnancy prevention needs. It is one of the few family planning services for which it may be appropriate to provide an in-person visit. Family planning providers should use the Interim CDC Guidance to make decisions about face-to-face activities depending on the local level of community transmission or impact of COVID-19.
Consistent with the Interim CDC Guidance, for any face-to-face activities, providers should implement symptom screening and triage patients before they come to the clinic, provide face masks to patients upon arrival, utilize physical distancing strategies to limit contact with patients at triage, emphasize hand hygiene, and provide appropriate PPE for staff‘s role. All health care staff and providers, as well as the client, should wear surgical masks during IUD and implant placements and removals. The reason for the client to don a mask is to protect the providers and staff in the room if she has incubating or pre-symptomatic COVID-19, as well as protecting herself from infection during a procedure where the rules of physical distancing from providers and staff can be difficult to achieve. See Beyond the Pill’s LARC Guidance During COVID-19 for more information.
A pre-visit telemedicine visit should occur where an initial screening is done to: a) determine whether the client is currently or has recently had symptoms suggestive of COVID-19 infection, if anyone they have been in contact with has been symptomatic, or if they or anyone they have been in contact with has been confirmed as having COVID-19, and (b) take care of any administrative needs as well as conduct counseling, education, answer questions. During the televisit, the provider should confirm with reasonable assurance that the woman is not pregnant and even assist the woman with taking a pregnancy test, if appropriate. This will help make the in-person visit as efficient as possible, thereby limiting exposure time.
What can family planning providers tell clients who ask about expired IUDs and implants?
There is evidence that IUDs and implants are likely to be effective longer than their FDA-approved duration. Summarized by the Reproductive Health Access Project, evidence-based duration is as follows:
|FDA-Approved Duration||Evidence-Based Duration|
|Nexplanon||3 years||5 years|
|Liletta||6 years||7 years|
|Mirena||5 years||7 years|
|Skyla||3 years||3 years|
|Kyleena||5 years||5 years|
|Paragard||10 years||12 years|
|DMPA||12 weeks||15 weeks|
If the IUD or implant truly has expired, even by the extended evidence-based duration, providers should:
- Reassure that leaving the method in beyond its expiration will not cause harm (i.e., the IUD does not need to be removed emergently once it has expired, as long as no warning signs are present).
- Prescribe another method until in-person services resume and the IUD can be exchanged.
- Advise and counsel clients to use condoms.
Should family planning providers still provide emergency contraception (EC)?
Yes. EC should still be provided. Recommendations regarding the use of levonorgestrel ECPs (LNg, Plan B®) and ulipristal acetate (UPA; Ella®) are unchanged, remembering that UPA is more effective than LNg ECPs 72-120 hours after unprotected intercourse and in women whose body mass index is 26 kg/m2 or higher. Given the time-sensitivity of this service, curbside pick-up or transmission of the prescription to a pharmacy for same-day pick-up is optimal. Consider providing counseling and offering a contraceptive method that can be obtained at the time of ECP pick-up.
Can family planning providers still offer the copper IUD for EC?
Yes. Although it may be more difficult to arrange for an in-person visit for placement of a copper IUD, this method is the most effective form of EC. See the section on IUDs and implants for information on recommended safety measures for the provision of a copper IUD as EC.
What is the alternative to in-person STD treatment services?
Syndromic treatment is defined as choosing a treatment for a condition based upon a “best guess” of the client’s diagnosis, utilizing symptoms and a description of physical findings, but without the use of laboratory tests. During the public health emergency, CDC has said that “Phone or telemedicine-based triage, including syndromic management of male urethritis, suspected primary or secondary syphilis, vaginal discharge and proctitis, could be implemented.”
For clients with vaginal discharge, syndromic treatment is more sensitive/specific for bacterial vaginosis and trichomonas than for chlamydia and gonorrhea (GC/CT). The CDC does not recommend treating clients with vaginal discharge for GC/CT without testing to verify the diagnosis. For clients with penile discharge, the interim CDC guidelines do recommend empiric treatment for GC/CT if testing is not available.
Syndromic management for making a diagnosis of herpes is quite variable and depends on the clients’ history of exposure and clinical presentation. In general, syndromic management for STDs can have issues with specificity (i.e., false positives, resulting in overtreatment), but may be necessary temporarily in some locations during this public health emergency.
See this one-page summary for treating symptomatic patients when in-person exams are limited, created the summary.
How can a client with a vaginal discharge or vulvar irritation be evaluated remotely?
If a client is having a recurrence of a vulvovaginal condition that was previously diagnosed, she can be offered treatment based on a telephonic or telemedicine visit.
For a new problem, obtaining a thorough history and conducting an assessment via telehealth can allow the provider to consider empiric treatment for vaginitis. For example, if the client has a malodorous vaginal discharge suggestive of bacterial vaginosis or trichomoniasis, metronidazole 500 mg orally twice a day for 7 days will treat either condition.
If they have vulvar irritation/itching and white, cottage-cheese like discharge, the client could be treated empirically with fluconazole 150 mg orally in a single dose, or could self-treat with over-the-counter antifungal products for vaginal yeast.
Some clinics have used curbside for pick-up and drop-off of vaginal discharge sampling kits, which include a stoppered-plastic or glass tube filled with 1 cc of fresh saline solution and a pack of sterile cotton tipped swabs. The client should be instructed to swab her vaginal walls to obtain a sample, immediately place the swab into the tube and cap it, then to drop it off at the clinic as quickly as possible for microscopic evaluation, given that trichomonads will live briefly in a light-filled aerobic environment.
If a client is having an episode of recurrent genital herpes, they can be offered treatment based on a telephonic or telemedicine visit.
Some clients may be willing to take a cell phone photograph of their genital skin rash and submit it to the clinician, given that it is a variant of the established practice of teledermatology. (Note: Many payers include this service, using a virtual check-in code, G2010, “Remote evaluation of recorded video and/or images submitted by an established client (e.g., store and forward), including interpretation with follow-up with the client within 24 business hours.”)
What if a client with vaginal discharge also has symptoms such as pelvic pain or dyspareunia?
In these cases, the client may have pelvic inflammatory disease and it would not be recommended to treat that empirically. The client should be referred for an in-person exam and antibiotic treatment.
What if the client has a genital or anal ulcer?
If the client is having an episode of recurrent genital herpes, they can be offered treatment based on a telephonic or telemedicine visit.
If this is a new ulcer, it may be helpful to have the client take a cell phone photograph of the ulcer and submit it to the clinician. Additionally, it is important to assess whether the client has any pain in the area surrounding the ulcer. Clients presenting with multiple painful ulcers (especially bilaterally) are more likely to have genital herpes, while those presenting with a single painless ulcer are more likely to have primary syphilis.
If syphilis is suspected, it is important to arrange for the client to have serologic tests for syphilis (such as an RPR and TP-PA), so that response to treatment can be monitored. For primary syphilis, if the client cannot receive injectable benzathine penicillin, then for non-pregnant clients the recommended treatment would be doxycycline 100 mg twice daily x 14 days. Pregnant clients with suspected syphilis must be referred for the intramuscular (IM) injection therapy; there are no acceptable alternatives.
Can family planning providers treat clients with possible gonorrhea or chlamydia contact without an in-person visit?
If the client has had sexual contact with a person known or suspected to have chlamydia, gonorrhea, or both, and diagnostic testing is not a possibility, empiric therapy for both pathogens is an acceptable alternative. This is true regardless of whether the client is presenting with symptoms or not, and regardless of the client’s gender identity of the gender of their sex partners.
If in-person injections are not a possibility, CDC recommended treatments including cefixime 800 mg orally and azithromycin 1 gram. This is a change from the 2015 CDC STD Treatment Guidelines, which previously recommended 400 mg of cefixime. If azithromycin is not available and the client is not pregnant, doxycycline 100 mg orally twice a day for 7 days is recommended. Additional recommendations on treatment of sexually transmitted diseases (STD) from CDC can be found in the CDC STD Division of STD Prevention guidance and summarized in this table.
How should family planning providers evaluate/treat a client with rectal symptoms, particularly if gonorrhea or chlamydia is suspected?
Ideally, those clients would have an in-person exam and testing for GC/CT. Because SARS-CoV-2 can be found in the stool of infected clients, having clients self-collect a rectal swab for GC/CT can minimize risk to the clinician. Find instructional handouts for clients on how to self-swab.
If testing is not an option, it is acceptable to treat the client empirically for proctitis. If IM treatment is not an option, then the client can be treated with cefixime 800 mg orally in a single dose, plus doxycycline 100 mg orally twice a day x 7 days. If the client is pregnant or doxycycline is not available, then azithromycin 1g orally in a single dose can be used.
What if the client has sore throat and suspects exposure to gonorrhea or chlamydia through oral sex?
Because pharyngeal sampling may cause the client to gag and cough, having clients self-collect a throat swab for GC/CT can minimize risk to the clinician. Find instructional handouts for clients on how to self-swab. If the client has pharyngeal symptoms and GC/CT is suspected, then they can be treated empirically. It is important to note, however, that symptomatic pharyngitis is more likely to be caused by non-sexually transmitted bacteria and viruses, and can also be caused by COVID-19.
Can family planning providers use expedited partner therapy (EPT) for gonorrhea or chlamydia treatment?
Yes, EPT can be made available to a partner(s) either by writing a prescription in the name of the partner or doubling the dose of the medications dispensed to the client. These approaches are even more critical during this public health emergency to avoid needing to see a client, or partners, during a face-to-face visit. For more detail, including links to state laws regarding EPT, refer to current CDC EPT guidelines.
What is the current advice on recommended timing for retesting a client with previously treated chlamydia infection?
CDC recommends retesting clients who have been treated for chlamydia approximately three months after completion of treatment in order to detect reinfection. While these recommendations have not changed during the public health emergency, providers are advised to consider using a system for obtaining a sample at a site other than your clinic (e.g., the client’s home).
Can family planning providers use at-home test kits for STDs as an alternative to in-clinic sampling?
There is a difference between at-home sampling and at-home screening test kits. At-home sampling can be done by at-home self-sampling of vaginal fluid or urine collection and in some cases, rectal or pharyngeal swabs with the same collection technique used in the clinic, then transported back to the clinic for curbside drop-off or to a contracted lab test-deposit site.
At-home STD screening test kits are either point-of-care tests, with an immediate result, or self-sampling with the specimen mailed to a commercial lab. These typically are sold directly to consumers or through on-line telehealth companies. More information about the options and how to use them can be found on KFF's site.
The types of tests offered vary from company to company, but often include HIV, GC/CT, syphilis, trichomonas. Some companies also offer throat/rectal swabs for GC/CT, as well as blood spot tests for syphilis and hepatitis C.
Do insurance companies pay for at-home sampling or at-home screening test kits?
It depends. Health insurance companies pay claims for laboratory tests based on whether the CPT code of the test is a covered benefit and performed in a contracted lab. If the client picks up a collection kit and lab slip for a test (ideally by curbside delivery), self-samples at home, drops off the test kit (with the lab slip) curbside at the clinic or lab office, and then has the same test run that she normally would have had, it should be covered.
If the CPT code for an at-home test kit is not a benefit of the payer, or if the test is run by a non-contracted lab, it is unlikely to be covered. Look up whether the CPT code of a lab test is a benefit of the client’s payer; if this information is not available online, then it is best to contact the health plan to find out. Equally important is determining whether the lab running the test is contracted with the health plan. Some PPO health insurance plans cover the costs of telehealth visits, medications, and at-home STD screening tests through online telehealth companies.
We heard there was a GC/CT testing shortage, should we change who we are screening?
STD screening rates have plummeted during the PHE. There are also regional shortages in supplies and laboratory capacity to run tests. The CDC recommends that when faced with limitations in resources, health care professionals should prioritize services that, if deferred, are most likely to result in client harm. Screening for GC/CT of asymptomatic, sexually active adolescents and women ages 24 years and younger remains an important public health priority.
Can Title X family planning providers accept the results of pregnancy tests performed by the client at home?
Yes. OPA has given guidance: “As long as the state of emergency exists, any services that [Title X agencies are] able to provide under normal circumstances that you can provide through telehealth will be considered Title X services.”
Does Medicaid accept results of at-home pregnancy tests to determine eligibility for Medicaid during pregnancy?
There is no national guidance from the Centers for Medicare & Medicaid Services (CMS) on this, so it is up to each state to determine their own criteria for pregnancy verification. Family planning providers should check the website of their state Medicaid programs to check on whether Medicaid has modified their policies to permit a home pregnancy test to be the sole determinant of pregnancy, as opposed to still requiring a clinic visit and clinician verification of pregnancy.
Can family planning providers continue to provide services to help clients achieve pregnancy during COVID-19?
Research suggests that pregnant women who become infected with COVID-19 are at increased risk for severe illness when compared to their non-pregnant peers, and the effect is greater for Black and Hispanic women. Individuals and couples should be provided with this information, but must be able to make their own decisions based on their own values, priorities, resources, and unique circumstances.
Family planning providers can continue to provide services to help clients achieve pregnancy, including basic infertility services using telehealth. For example, family planning providers can provide counseling on fertility awareness and preconception health.
Though prenatal care services are outside the scope of Title X, Title X providers are required to refer for medically necessary prenatal care. The American College of Obstetricians and Gynecologists (ACOG) has issued comprehensive and detailed guidelines regarding the timing and content of prenatal care visits. They can be found in COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics.
In addition, ACOG and the Society for Maternal Fetal Medicine have developed an algorithm for the Outpatient Assessment and Management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19).
What advice should family planning providers provide regarding sexual practices during the pandemic?
There are no evidence-based national guidelines on this subject yet, which makes counseling and health education difficult. What is known is that COVID-19 is spread by saliva droplets, which are likely to be exchanged during sexual intercourse. According to research out of China released on May 7th in the Journal of the American Medical Association, SARS-CoV-2 has been detected in the semen of men with acute infection and those that are recovering from infection. The independent contribution of the virus in semen is unclear as there are also respiratory droplets and saliva that are often exchanged during sex. Based on small studies out of China among women with severe COVID-19 illness, SARS-CoV-2 is not detectable in vaginal fluid.
Can family planning providers continue to provide the second or third doses of HPV vaccines?
National guidelines imply that the second or third doses are not time-sensitive and that administering them can be postponed until after the public health crisis. The CDC Pink Book states: “There is no maximum interval between doses. If the HPV vaccine schedule is interrupted, the vaccine series does not need to be restarted. If the series is interrupted after the first dose, the second dose should be given as soon as possible, and the second and third doses should be separated by an interval of at least 12 weeks. If a third dose is indicated and only the third dose is delayed, it should be administered as soon as possible.” The Immunization Action Coalition also states that the HPV vaccine series does not need to be restarted because of an interval that is longer than recommended. Providers should continue the series where it was interrupted.
How should family planning providers manage women who were found to have abnormal cytology results?
Given that progression through the stages of cervical dysplasia is a very slow process over the course of years for most women, family planning providers may want to reschedule colposcopic evaluation and follow-up visits until the time that face-to-face office visits are resumed. The American Society for Colposcopy and Cervical Pathology (ASCCP) have issued the following ASCCP Interim Guidance during COVID-19 Pandemic:
- LSIL: postpone diagnostic evaluations up to 6–12 months
- HSIL, ASC-H: documented attempts to contact and diagnostic evaluation scheduled within 3 months
- High-grade cervical disease without suspected invasion
- Documented attempts to contact and procedures scheduled within 3 months
- Suspected invasive disease
- Contact attempted within 2 weeks and evaluation within 2 weeks of that contact (4 weeks from the initial report or referral)
Can cytology screening be completed at time of IUD insertion if the client is due for a Pap test?
Yes. However, the two issues are separate. According to CDC Selected Practice Recommendations, clients do not have to undergo cervical cancer screening or have a negative result before an IUD can be placed. If the client is due for cervical cancer screening, it is reasonable to use the visit for her IUD placement as an opportunity to do cervical cancer screening too.
What services are family planning providers delivering virtually (i.e., via telehealth)?
Everything, except IUD and implant placements and removals can be provided virtually. The shared decision-making client-centered counseling can be done remotely, following which the client may come to the service site for the procedure, if in-person services are being offered.
Should family planning providers consider "hybrid" televisits in which providers are doing the televisits from home and clients are at the center for labs and blood pressure checks with a nurse or medical assistant?
Hybrid visits can be an effective way of meeting client needs while also limiting their time in the clinic. The provider/program can determine whether hybrid visits are an option at their site and under what circumstances. However, this approach may involve more in-clinic presence than is necessary. Non-clinic alternatives for BP checks are listed above, and many test sampling kits can be done by curbside pick-up. Blood draws, if necessary, can be done at a laboratory satellite site if it is more convenient than a clinic. The approach should be tailored to the specific circumstances of the community.
Are there national guidelines on a preferred method of prioritizing visit types according to which should be done in-person, virtually (i.e., telehealth using audio only or audio and video), or postponed?
The American College of Obstetricians and Gynecologists has published recommendations regarding prioritization of gynecologic visits, including a section on how should provision of contraception be optimized? Highlights include:
- Telehealth can be used to screen new clients requesting contraceptives that can be self-administered; clients may be safely screened and offered prescriptions if they do not have contraindications. Manage adverse effects related to contraceptives by telehealth, when possible.
- Prescription Refills: Refills for existing prescriptions can be made through telehealth. Prescribe enough refills to minimize trips to the pharmacy—ideally for a full year. Encourage clients to fill prescription contraceptives by mail or at drive-through pharmacies, when available.
- Emergency Contraception: Counsel clients on the use of EC, including both over-the-counter and prescription options. Provide advance prescriptions for EC, particularly for ulipristal acetate.
- Continue to offer insertion and removal of long-acting reversible contraception (LARC). If provision of LARC methods or permanent contraception is unavailable during this pandemic, offer contraceptives that can be self-administered until placement is possible.
Clinics are advised to develop a written policy that prioritizes which client visits will be done in person or remotely. It is critical to revise the policy frequently based on current local or state physical distancing laws, the availability of clinician and non-clinician staff (especially if absences are prevalent due to infection, self-isolation, caring for family members, etc.), available supplies of personal protective equipment (PPE), etc. See the FPNTC’s Prioritization of In-Person and Virtual Visits During COVID-19: A Decision Making Guide for Staff for more information.
Can telehealth visits ever be telephonic-only (i.e. without visual)?
An “audio-only” or “telephonic-only” telehealth visit may be necessary if a clinic does not have a telehealth platform with both audio and visual function; the client doesn’t have access to a computer or a smartphone; internet access is unavailable or slow; or for certain short, limited interactions with a clinician. During the public health emergency, Medicare and some third-party payers have modified their rules so that “telehealth visits”, which previously required audio and video communication, can be performed by telephonic-only.
During the public health emergency, both audio-visual and telephonic-only visits are considered to be “an encounter” by OPA and reportable for FPAR. Providers should check with their state Medicaid, Medicaid managed care health plans, and state family planning programs to see if telephonic-only visits are acceptable substitutes for audio/video visits.
What codes are used to bill for telephonic-only visits?
It may be possible to bill for a telephonic-only visit depending on the circumstance. Clinicians may be able to bill:
- A virtual check-in visit (G2012, defined below)
- One of the 3 long-standing Evaluation and Management (E/M) codes for telephonic visits: 99441 (5-10 minutes of medical discussion), 99442 (11-20 minutes), or 99443 (21-30 minutes)
- A telehealth visit (an E/M code with a -95 modifier; place of service -02), if the payer has a written policy that permits this during the public health emergency
As always, it is critical to understand the policies of each payer regarding the use of these codes for telephonic-only visits. See the American Academy of Family Physician quick reference guide to differentiate and code virtual visits.
What is a virtual check-in visit and who can bill this type of visit?
CMS defined the rules for virtual check-in visits in 2019 for use in the Medicare program. As a consequence of the public health emergency, many state Medicaid programs and state family planning programs have added this benefit. A virtual check-in visit is defined by CMS as a brief communication technology-based service (including synchronous discussion over a telephone or exchange of information through video or image) by a physician or other qualified health care professional who can report E/M services, provided to an established client, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. The client must verbally consent to receive a virtual check-in visit. The HCPCS code 2012 is used.
On March 6, 2020, CMS expanded these criteria for Medicare clients and stated that “to the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.”
Can a practitioner bill for the time spent charting and accessing the telehealth platform?
If using time-based coding, the time is calculated by face-to-face time with the client in both in-person and virtual visits (not logging on or documenting after the visit). However, charting can be done simultaneously with the client interaction. Time-based coding can be used if more than half of the face-to-face time (in the office or other outpatient setting) is spent on counseling or coordinating care.
Significant changes in the rules about E/M coding based on time will be implemented in 2021, including the ability to factor-in time spent on charting. Timelines for phasing in these important changes will be payer-specific, so providers should not change over to coding and billing in this manner until payer(s) give specific start dates for doing so.
We conduct some parts of the visit virtually (i.e. history and counseling) and then bring the client to the clinic for the exam/procedure. Does this visit “count” as a telehealth visit for documentation and reimbursement?
Yes. This approach is referred to as a “hybrid” visit, since the first part is done by telehealth and the second part is done in-person. If the remote visit is coded as a telehealth visit (audio-visual communication or telephonic-only, if permitted) or using one of the telephonic visit codes (99441-3, if covered), followed by an office visit or procedure, both claims should be paid. However, a virtual check-in visit (HCPCS code G2012) cannot be used for a hybrid visit if the in-person occurs within the next 24 hours (or soonest available appointment).
What resources are available about billing for telehealth services?
For information about billing for telehealth services, see Medicare’s list of payable telehealth services, the Coding with Ann Telehealth Podcast from the Clinical Training Center for Family Planning, National Family Planning and Reproductive Health Association’s Coding and Billing for Telehealth Services, and the American Academy of Family Physician quick reference guide to differentiate and code virtual visits.
How are consents obtained if a client and provider are not co-located?
Consent can be obtained verbally during the public health emergency. Verbal consent should be documented in the client’s record. A digital copy should be shared with the client, if possible. Providers should obtain written consent when the client returns to the clinic. The consent language should explain what the telehealth or phone consult is, expected benefits and possible risks associated with it, and security measures. Example documentation in the record may include: “Verbal consent to treat obtained via phone, and written consent will be obtained when the client comes to the clinic. Consent reviewed in detail with client, digital copy shared, and client verbalized understanding.”
States have varying informed consent requirements. Sometimes healthcare professionals must obtain informed consent each time telehealth is used, while other laws only require informed consent for the first telehealth visit in a series of visits for the same condition.
How are clients able to verify family size and income if receiving services virtually?
Title X grantees are responsible for specifying the process they follow for verifying client income. Grantees may elect to have a uniform policy for income verification across all sub-recipients. Alternatively, they may elect to leave income verification policies up to individual sub-recipient agencies as long as the grantee ensures that Title X regulations are followed. The process must be specified in an agency’s policies and procedures. For example, a policy may state that income can be obtained verbally or that sources of documentation are expanded and/or may be provided via email or at the time of the next in-person visit. See the Defining Family Income for Title X Charges, Billing, and Collections Job Aid.
Should telehealth consents be dated with the date the services began (i.e. the date the consent was obtained) or the date the client returned to the clinic?
Telehealth consults should be dated with the date that consent was obtained.
As telehealth services appear to be a longer-term solution to care delivery, what platforms and practices should we implement to ensure privacy and confidentiality?
Maintaining client privacy and compliance with the Health Insurance Portability and Accountability Act (HIPAA) is as important virtually as it is during in-person visits. Clients who receive virtual visits should virtually sign or verbally consent to services. Many electronic medical records (EMR) have integrated telehealth video platforms which are HIPAA-compliant. Telehealth platforms that are integrated into EMRs can be efficient and acceptable to providers who are able to stay within one system rather than toggling between platforms.
However, if this is not an option, health care providers can provide telehealth services with technology vendors that are HIPAA-compliant and that will enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products. According to the Office for Civil Rights (OCR) at the Department of Health and Human Services, such vendors may include: Skype for Business / Microsoft Teams; Updox; VSee; Zoom for Healthcare; Doxy.me; Google G Suite Hangouts Meet; Cisco Webex Meetings / Webex Teams; Amazon Chime; GoToMeeting; and Spruce Health Care Messenger. Note that OCR has not reviewed the BAAs offered by these vendors, and this list does not constitute an endorsement, certification, or recommendation of specific technology, software, applications, or products.
The National Family Planning and Reproductive Health Association (NFPRHA) resource, Initiating Telehealth in Response to COVID-19: Initial Considerations and Resources, provides a table (page 6) analyzing telehealth platforms with HIPAA-compliant video connection. The table details how the telehealth platforms can be launched, pricing, and other notes and considerations. The American Academy of Family Physicians also offers details about telehealth platforms known to be used in private practice, along with questions to ask potential telehealth vendors.
In addition to ensuring HIPAA compliance, providers can use this Telehealth Visit Etiquette Checklist, developed by the American Medical Association, to ensure that the professional standards of in-person care is maintained in a virtual environment.
While telehealth visits with video are preferable so the provider can establish rapport with and obtain a visual assessment of the client, an “audio-only” or “telephonic-only” telehealth visit may be necessary. During the public health emergency, Medicare and some third-party payers have modified their rules so that “telehealth visits”, which previously required audio and video communication, can be performed by telephonic-only. See Can telehealth visits ever be telephonic-only (i.e. without visual)?
For more help in understanding and evaluating technology options and platforms, reach out to the National Telehealth Technology Assessment Resource Center (TTAC)
What does it look like to provide curbside pickup?
OPA has endorsed the option of curbside pickup for providing methods or medication supplies during the public health emergency. Appropriate PPE should be used (e.g. gloves that are changed between each interaction, and use of a face mask). Use procedures to use physical distancing strategies; for instance, one option is to put the medication on a table, walk away, and allow the client to get out of the car, pick it up and drive away. Another is to walk the medication or test kit to a car, place the package on the hood of the car, and have the client retrieve it. Medications should be clearly labeled and documented in the medical record just as if it were given in-person. There must also be a way to verify the client’s identity; some clinics do this by having the client text their auto license plate number to insure that the delivery is made to the correct person.
During curbside pickup of medications, is there any reason why non-licensed staff couldn’t help the process by handing medication to the client?
Family planning providers should follow the same dispensing policies that are used for in-clinic dispensing of medications. Each state has different laws and regulations around who can hand medications to the client, so in a state where non-licensed staff can not hand medications to the client within the clinic, the same applies to curbside. Providers should develop a policy for curbside delivery of medication that is consistent with in-clinic policies.
How can family planning providers deliver medication by mailing it to clients at home?
OPA supports the option of mailing prescriptions or supplies to clients at home during the public health emergency, if the client has no concern with confidentiality and consents to having supplies mailed to their address. Medications should be clearly labeled and documented in the medical record just as if they were provided in-person. Family planning providers should consult their state’s pharmacy regulations.
For insured clients, family planning providers can encourage them to ask their pharmacies to deliver medications; in some communities, pharmacies are offering free or low-cost delivery during the public health emergency. Some insurance companies are also offering mail-order options for clients.
How can we effectively utilize nurses and medical assistants when they are working from home?
It is likely that nurses and medical assistants can continue to provide many of the same services that they provided at the clinic, while at home. For example, providing client-centered counseling and education that they have been trained to conduct, using telehealth. Many video conferencing services provide the option of a virtual waiting room, as do some electronic health record telehealth systems. They can also call or contact clients to let them know that services are still available, send reminders, promote available, no-contact services via social media, conduct outreach, conduct quality assurance activities, participate in training, etc. Staff should continue to use client-centered practices in accordance with QFP recommendations while providing services virtually, including using a professional, distraction-free environment, maintaining client confidentiality, and fostering a relationship built on trust, rapport, and shared decision making.
Should a clinic reopening for in-person services stop providing telehealth and just provide in-person again?
Until the PHE passes, service providers are encouraged to maximize the use of all telehealth modalities. For clinics that have been providing mostly virtual services throughout the PHE, start slow and work toward reopening with a gradual increase of in-person visits. After the PHE, telehealth services can be added to the menu of options for clients. Telehealth is a convenient option for many clients, and has the potential to improve access and increase equity. For more information, go to the Telehealth section (above). For more on telehealth for women’s preventive health services, see the Women’s Preventive Services Initiative Telehealth FAQ for Preventive Care.
What services should be prioritized for in-person visits?
Prioritize at-risk populations, including those most at-risk for complications from delayed care and those without access to telehealth services. Services can be prioritized using the Prioritization of In-Person and Virtual Visits During COVID-19: A Decision-Making Guide for Staff. A phased and measured approach to reopening over time may begin after there has been a sustained decline in prevalence and spread in your community. Key considerations for the resumption of comprehensive women’s health care services from the American College of Obstetricians and Gynecologists include identifying if you have adequate staff, an ability to maintain physical distancing, and/or adequate personal protective equipment when you are not.
How can we keep clients and staff safe?
As the pandemic has lasted longer than originally anticipated, health care facilities must balance the need to provide necessary clinical services while minimizing risk to clients and staff. Because the burden of COVID-19 varies among communities, facilities must consider the local level of COVID-19 transmission when making decisions about providing family planning and preventive health services.
Some strategies that have helped to maintain physical distancing include:
- Limit in-person visits for clients who require physical evaluation or interventions and maximize use of telehealth and no-contact services to reduce the number of clients in the clinic.
- Consider expanded hours to enable the spacing out of staff and providers.
- Change spacing and arrangement of furniture and marking floors and elevators for one-way traffic, spaced-out waiting, and a limited number of individuals in a given space.
- Have clients wait in their cars and call/text to check in and to be notified for when their room is available.
- Provide hygiene stations for clients to use before entering the facility or waiting room.
- Have a clear and consistent policy for personal protective equipment and universal face coverings for clients, staff, and providers.
What personal protective equipment (PPE) is needed?
Given the potential for asymptomatic transmission of COVID-19, CDC recommends that health care personnel providing in-person care to clients not suspected or confirmed to have COVID-19 follow proven infection control practices. The CDC has provided specific considerations for care of clients not suspected or confirmed to have COVID-19 when there are moderate or substantial levels of community transmission.
The CDC recommends that all clinical care facilities, such as family planning clinics, use standard precautions for all client care including:
- Place visual alerts, such as signs and posters in appropriate languages and reading levels, at entrances and in strategic places providing instructions on how to stop the spread of germs through hygiene and physical distancing, the importance of masks, and what to do if the person has symptoms.
- Develop clear policies regarding optimizing PPE availability and use; masking, and hand hygiene for clinicians, staff, and clients are also necessary.
- Enforce a universal mask policy for clinicians, clients, and visitors.
- Cloth face coverings are not considered PPE. Health care personnel should wear appropriate PPE. Cloth face coverings should NOT be worn instead of PPE.
- Use of eye protection is recommended in areas with moderate to substantial community transmission. For areas with minimal to no community transmission, eye protection is considered optional, unless otherwise indicated as part of standard precautions.
Should we screen staff and clients before they arrive?
Clients should ideally be screened by phone before arriving; if this is not possible, they can be screened before entering the facility: CDC COVID-19 sample screening tool. If the client reports symptoms or exposure to a person with COVID-19 infection, the client should be instructed not to come for the family planning visit and should be referred to an appropriate health care and/or public health facility.
Staff can self-screen before coming to work. If they answer “yes” to any of the screening questions they should not enter your facility.
Because of the risk of exposure to COVID-19, it may be necessary to modify policies about bringing family or friends to a visit. Although there may be exceptions based on individual circumstances, as a general rule, clients should be asked to come to the visit alone to limit exposure to staff and other clients.
How will clients know they can receive in-person services again?
Some sites have reached out to clients who cancelled appointments previously—or who are due for routine services or refills—to let them know how they can meet their reproductive health care needs. In addition, you can reach out virtually. For example, family planning sites can use the FPNTC Social Media Toolkit, which provides sample social media content and images, to communicate important information about the availability of and changes to their services. You can also reinforce COVID-19 prevention and infection prevention messages with the CDC Social Media Toolkit.
What if a staff member gets exposed?
If a staff member is exposed to an individual with COVID-19, they should follow the CDC guidelines for quarantine and at a minimum stay home for 14 days after the last contact with a person who has COVID-19. If staff are exposed—even if they test negative for COVID-19 or feel healthy—they should stay home (quarantine), since symptoms may appear 2 to 14 days after exposure to the virus. The guidance for returning to work changes regularly; follow the CDC recommendations and your state or local health department protocol for exposure to known or possible COVID-19 infection.
Testing of health care personnel should be considered in these situations:
- Testing those personnel with signs or symptoms consistent with COVID-19
- Testing asymptomatic personnel with known or suspected exposure to COVID-19
- Testing personnel who have been diagnosed with COVID-19 infection to determine when they are no longer infectious
Providing family planning services in-person is stressful. How can we support our staff?
These are unprecedented and difficult times for everyone. It is important for staff and providers to feel supported, as they navigate unfamiliar circumstances and transition to new models of care. Take time to listen and process feelings as they come up. Share tips and strategies to Help Staff Reduce Stress During COVID-19. Recognize and normalize the stress and anxiety; also give space to staff to build resilience to help everyone get through this difficult time.
Last Updated October 5, 2020
Note: This toolkit contains links to outside sources which may refer to services outside the scope of Title X (including care for pregnant individuals). The views expressed do not necessarily reflect the views of FPNTC or HHS/OASH/OPA, nor should inclusion be construed as an endorsement by FPNTC or HHS/OASH/OPA.