Women's Cancer Screening Program Information for Healthcare Providers
The Rhode Island Women's Cancer Screening Program provides no-cost pelvic exams, Pap tests, clinical breast exams, and mammograms (breast x-rays) to eligible Rhode Island women. The program also covers many diagnostic tests. (more)
Patient Enrollment, Screening, and Referral
Eligible women must be enrolled in the WCSP at a participating provider office. New enrollment forms should be completed at the office visit every year when women are screened (more). If a client is new to your facility, have her complete an enrollment form. (This helps the Women's Cancer Screening Program track clients through the screening and follow-up process.) The bottom line: When in doubt, enroll!
For eligible women, we can fund:
- Cervical cancer screening (Cytology alone every 3 years, or Cytology and HPV test together every 5 years).
- Breast cancer screening (mammogram and clinical breast exam every year).
- Diagnostic services, if an abnormality is found in a screening test.
At the office visit, a women's health exam should consist of a pap smear, pelvic exam, and a Clinical Breast Exam (CBE). Each participant must be enrolled in the Women's Cancer Screening Program at a participating provider office before she is given a referral for a mammogram. All Rhode Island radiology facilities participate in the WCSP.
Use your 3-digit Women's Cancer Screening Program number or office stamp on enrollment and screening forms to indicate where the client was enrolled into the Women's Cancer Screening Program. The Women's Cancer Screening Program stamp must also be used on Pap smear requisitions, mammogram referrals, or other outside orders so that the lab or radiology facility will invoice the WCSP and not the client for services provided.
To find out if a CPT is reimbursable, refer to the current Provider Reimbursement Schedule. Please note the following restrictions on reimbursement of HPV testing , endometrial biopsies, and Pap tests following hysterectomy:
- The Women's Cancer Screening Program can reimburse for HPV testing (High Risk Types of HPV only) in the following situations:
- Screening with a combination of cytology (Pap test) and HPV testing every 5 years.
- Reflex HPV test for Pap test result of ASC-US.
- Initial workup, or subsequent management, of a Pap test result of Atypical Glandular Cells (AGC).
- Follow up (surveillance) at one year for women with CIN 1 or less on histology following colposcopy and biopsy preceded by an ASC-US, ASC-H, or LSIL Pap result.
- Pap tests following hysterectomy: The Women's Cancer Screening Program cannot reimburse for cervical cancer screening in women with total hysterectomies (i.e., those without a cervix) unless the hysterectomy was performed because of cervical neoplasia (precursor to cervical cancer) or invasive cervical cancer, or if it was not possible to document the absence of neoplasia or reason for the hysterectomy.
- Endometrial biopsies are reimbursable in the following situations:
- Initial workup of a Pap test result of Atypical Glandular Cells (AGC).
- The Pap test of a postmenopausal woman shows endometrial cells.
- Breast Magnetic Resonance Imaging (MRI) are reimbursable in the following situations:
- In conjunction with a mammogram when a client has a BRCA mutation,
- A first-degree relative who is a BRCA carrier,
- A lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO that are largely dependent on family history,
- To better assess areas of concern on a mammogram or for evaluation of a client with a past history of breast cancer after completing treatment.
- Services for women younger than 40 years old: According to the Centers for Disease Control and Prevention, being at high risk (e.g., those with a strong family history of breast cancer), does not qualify women younger than age 40 for reimbursable breast screening through the WCSP. The WCSP also does not cover the cost of Pap tests or cervical diagnostic services, including colposcopy, for any women younger than age 40. However, the WCSP will continue to facilitate access to treatment for women at any age who meet Women's Cancer Screening Program income and insurance criteria and who have been recommended for LEEP or Cone procedures. If these women do not meet Medical Assistance eligibility requirements (see below), the Women's Cancer Screening Program will cover the cost of LEEPs and Cones.
- Procedures specifically not allowed by CDC:
- Computer Aided Detection (CAD) in breast cancer screening or diagnostics;
- Treatment of breast cancer, cervical intraepithelial neoplasia, and cervical cancer. Please note: Coverage for the cost of treatment may be available through the Rhode Island Medical Assistance program (see below).
Treatment through the Medical Assistance Program
As an extension of the Women's Cancer Screening Program, women may be eligible to apply for Medical Assistance (Medicaid) to cover the cost of treatment for a precancerous condition of the breast/cervix or a diagnosis of breast or cervical cancer. In order to qualify for Medical Assistance through the Women's Cancer Screening Program, a woman must:
- Meet the eligibility requirements for enrollment in the Women's Cancer Screening Program. ( more)
- Be a US citizen (and show proof) or be a qualified immigrant for a minimum of five years (and provide a copy of her permanent resident alien card). Please note: a working VISA or a copy of a social security card is not considered proof of permanent resident alien status.
- Show proof of Rhode Island residency (driver's license, utility bill, etc.).
- Have no other individual or group insurance. Please note: Women with Medicare part A and/or B are not eligible for Medical Assistance through the WCSP.
What You Should Do
- Help clients apply for Medical Assistance using the 1-page form created specifically for the treatment component of the WCSP. Only complete a Medical Assistance application when a client has been recommended to have treatment procedures for:
- Cervical cancer or a precancerous cervical condition (e.g., LEEPs, Cones, hysterectomy, etc.).
- Breast cancer or a precancerous breast condition (e.g., all surgical, stereotactic, and ultrasound guided biopsies, etc.).
- Complete a Verification of Need form for clients.
- Gather copies of the client's proof of citizenship, proof of Rhode Island residency, and Social Security card, if available.
- Complete, date, and sign DHS form DHS-922.
- Mail original copies of these forms and copies of supporting documents to the Case Management Coordinator at the Rhode Island Department of Health. For help with this process, please call 401-222-1151.
- Contact the Women's Cancer Screening Program to order additional forms.
What We Will Do
As soon as all required forms are received, the WCSP Case Management Coordinator will meet with a representative from the Department of Human Services to determine eligibility (usually within 7 days of receipt of completed application). The Case Management Coordinator will call the provider site that initiated enrollment to let them know if the patient is enrolled in Medical Assistance and the effective date of enrollment. The WCSP fiscal staff will contact each provider site that has submitted invoices to the WCSP to inform them of the client's Medical Assistance coverage for any pending payments.
Duration of Eligibility for Medical Assistance
A woman with a pre-cancerous condition of the breast or cervix is eligible for Medicaid services for 4 months. A woman with a diagnosis of breast or cervical cancer is eligible for Medicaid services for one year. Prior to the end the woman’s eligibility period, the Department of Human Services will send the woman a re-determination letter.
If she continues to need treatment for a precancerous condition of the breast or cervix, or breast or cervical cancer, she must have her provider complete the re-determination form and return it to Department of Human Services. If the provider confirms that treatment is needed, Department of Human Services will extend the Medical Assistance benefit until the woman completes treatment or has access to other health insurance coverage. This process will continue as long as she needs treatment, as verified by a clinician.
During her eligibility period, a woman is entitled to the full scope of services available through Medical Assistance. In other words, coverage is not limited to treatment of a pre-cancerous condition or diagnosis of cancer. A woman will not be removed from Medical Assistance without prior correspondence from the Department of Human Services office.