WSR 04-05-011

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed February 6, 2004, 4:34 p.m. ]

Date of Adoption: February 3, 2004.

Purpose: Implementing regulatory improvement under Executive Order 97-02.

These rules are being amended to identify which Medical Assistance Administration (MAA) clients are eligible for family planning services; to state what family planning services will be available to the eligible clients; how the services will be delivered and how the service providers will be paid. New WAC sections adopted: WAC 388-532-001, 388-532-110, 388-532-120, 388-532-130, 388-532-140, 388-532-500, 388-532-510, 388-532-520, 388-532-530, 388-532-540, and 388-532-550.

Citation of Existing Rules Affected by this Order: Amending WAC 388-532-050 and 388-532-100.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.09.800.

Adopted under notice filed as WSR 03-12-067 on June 2, 2003 and WSR 03-18-108 on September 2, 2003.

Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing changes, have been made to the rules as proposed (additions indicated by underlined text, deletions indicated by strikethrough text):

AMENDED SECTIONS


WAC 388-532-050

1. "... Defined words and phrases are bolded when they first appear in the text."

2. "Family planning only program" means the program providing an additional ten months of family planning services to eligible woman [women] who have just ended a pregnancy or completed a delivery. This benefit follows the sixty-day postpartum coverage for women who received medical benefits during the pregnancy.

WAC 388-532-100(1)

3. (d) TAKE CHARGE;

(d) (e) General assistance unemployable (GAU) No out-of-state care; and

(e) (f) Limited casualty program-medically needy program (LCP-MNP).

WAC 388-532-100(2)

4. "Healthy Options enrollees may self-refer outside their plan (HMO) or primary care case managerment for family planning services to:..."


NEW SECTIONS


WAC 388-532-110(2)

5. "Family planning clinic providers must:..."

WAC 388-532-130

6. (1) The following are not considered family planning services and are not covered under this chapter.

(1a) Infertility treatment services;

(2b) Abortions;

(3c) Mammograms;

(4d) Menopausal treatment services;

(5e) Cancer screenings (except for pap smears or other similar screenings as identified in published billing instructions for Family Planning Services); and

(6f) All other reproductive health care, health care services or primary care services and prenatal care services.

(2) See chapter 388-530 WAC, Pharmacy services and chapter 388-531 WAC, Physician-related services for coverage of items and services not provided under this chapter.

WAC 388-532-500

7. ..."This benefit follows the sixty-day postpartum coverage for women who received medical benefits for during the pregnancy..."

WAC 388-532-510

8. "A woman is eligible for family planning only (FPO) services if:..."

WAC 388-532-520

9. "In order to be reimbursed by MAA for family planning only services:..."

WAC 388-532-520(2)

10. "Family planning clinic providers must..."

WAC 388-532-520 (2)(a)

11. "Meet the requirements in chapter 388-502 WAC; and..."

WAC 388-532-530

12. "The following family planning only services are provided under this program:..."

WAC 388-532-550(2)

13. "Except as noted in subsection (3) of this section, MAA reimburses providers for covered family planning only services using MAA's published fee schedules."

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 11, Amended 2, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 11, Amended 2, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

February 3, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3214.6FAMILY PLANNING SERVICES
NEW SECTION
WAC 388-532-001   Purpose.   The department of social and health services (DSHS) informs eligible clients about available family planning services. This chapter contains the medical assistance administration's (MAA) rules for family planning services.

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AMENDATORY SECTION(Amending WSR 02-21-021, filed 10/8/02, effective 11/8/02)

WAC 388-532-050   ((Family planning)) Definitions.   (("Family planning services" means the services, including the use of contraceptive techniques, that a client uses to plan the number and spacing of the client's children.)) The following definitions and those found in WAC 388-500-005, Medical definitions, apply to this chapter.

"Complication" for the purposes of this chapter, means a condition occurring subsequent to and directly arising from the family planning services received under the rules of this chapter.

"Contraception" for the purposes of this chapter, means preventing pregnancy through the use of contraceptives.

"Contraceptive" for the purposes of this chapter, means a device, drug or product used to prevent pregnancy.

"Family planning only program" means the program providing an additional ten months of family planning services to eligible women who have just ended a pregnancy or completed a delivery. This benefit follows the sixty-day postpartum coverage for women who received medical benefits during the pregnancy.

"Family planning services" means medical care, contraceptives, and educational services which enable individuals to avoid unintended pregnancy.

"MAA-approved family planning provider" means a physician, ARNP or clinic that has been approved for and assigned a family planning provider number.

"Medical identification card" means the document MAA uses to identify a client's eligibility for a medical program.

"Over-the-counter (OTC)" means available for sale without a prescription.

"Principal purpose diagnosis of family planning" means the reason for the service or intervention is primarily for family planning purposes.

"Sexually Transmitted Disease Infection (STD-I)" is a disease or infection acquired as a result of sexual contact.

"TAKE CHARGE" means a five-year demonstration project that provides family planning to men and women with income at or below two hundred percent of the Federal Poverty Level. (Rules for the TAKE CHARGE demonstration project can be found immediately following these family planning services rules.)

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 2(12). 02-21-021, 388-532-050, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. 00-14-066, 388-532-050, filed 7/5/00, effective 8/5/00.]


AMENDATORY SECTION(Amending WSR 02-21-021, filed 10/8/02, effective 11/8/02)

WAC 388-532-100   ((Family planning services)) Client eligibility.   (1) The ((department informs eligible clients about available family planning services. This service includes, but is not limited to, information about the synthetic progestin capsule implant form of contraception.

(2) For eligible clients, except those participating in the TAKE CHARGE demonstration and research program (see WAC 388-532-700 through 388-532-790 for complete program description), the department provides the following services when needed in conjunction with family planning:

(a) Physicians' services;

(b) Advanced registered nurse practitioners' (ARNP) services;

(c) Clinic or hospital services;

(d) Laboratory services; and

(e) Contraceptive supplies and/or prescription drugs)) medical assistance administration (MAA) covers family planning services for clients eligible for the following "scope of care" designations (see WAC 388-529-0100):

(a) Children's health insurance program (CHIP);

(b) Categorically needy program (CNP);

(c) Family planning only;

(d) TAKE CHARGE;

(e) General assistance unemployable (GAU), no out-of-state care; and

(f) Limited casualty program-medically needy program (LCP-MNP).

(2) Healthy Options enrollees may self-refer outside their plan (HMO) or primary care case management for family planning services to:

(a) An MAA-approved family planning provider; or

(b) A pharmacy.

(3) MAA does not cover family planning services for clients in any program that does not meet the conditions of subsection (1) of this section.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 2(12). 02-21-021, 388-532-100, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. 00-14-066, 388-532-100, filed 7/5/00, effective 8/5/00.]


NEW SECTION
WAC 388-532-110   Provider requirements.   In order to be reimbursed by MAA for family planning services:

(1) Physicians and ARNPs must:

(a) Meet the requirements in chapter 388-502 WAC, Administration of medical programs--Provider rules; and

(b) Provide only those services that are within the scope of their licenses.

(2) Family planning providers must:

(a) Meet the requirements in chapter 388-502 WAC;

(b) Provide medical information and education about Food & Drug Administration (FDA) approved prescription birth control methods and over-the-counter birth control supplies, to eligible clients who request such services; and

(c) Sign a special agreement that allows the provider to bill for family planning laboratory services provided to Healthy Options enrollees through an independent laboratory certified through the Clinical Laboratory Improvements Act (CLIA). See WAC 388-532-140 (2)(c) for more information on handling laboratory services for managed care clients.

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NEW SECTION
WAC 388-532-120   Covered services.   MAA covers the following family planning services:

(1) Services for women

(a) Gynecological exam as medically necessary.

(b) Food & Drug Administration (FDA) approved prescription contraception methods as identified in chapter 388-530 WAC, Pharmacy services.

(c) Over-the-counter (OTC) contraceptives, drugs and supplies (as described in chapter 388-530 WAC, Pharmacy services).

(d) Sterilization procedure that meets the requirements of WAC 388-531-1550(1), if it is:

(i) Requested by the client; and

(ii) Performed in an appropriate setting for the procedure.

(e) Services such as laboratory exams, tests and procedures, and screening and treatment for STD-I when:

(i) Performed in conjunction with a principal purpose diagnosis of family planning; and

(ii) Required as part of the client's selected contraceptive method(s).

(f) Education on all FDA-approved contraceptives, natural family planning and abstinence.

(2) Services for men

(a) Over-the-counter (OTC) contraceptives, drugs and supplies (as described in chapter 388-530 WAC, Pharmacy services).

(b) Surgical sterilization procedure that meets the requirements of WAC 388-531-1550(1), if it is:

(i) Requested by the client; and

(ii) Performed in an appropriate setting for the procedure.

(c) Screening and treatment for sexually transmitted diseases-infections (STD-I) when:

(i) Performed in conjunction with a principal purpose diagnosis of family planning; and

(ii) Required as part of the client's selected contraceptive method(s).

(d) Education on all FDA-approved contraceptives, natural family planning and abstinence.

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NEW SECTION
WAC 388-532-130   Noncovered services.   (1) The following are not considered family planning services and are not covered under this chapter.

(a) Infertility treatment services;

(b) Abortions;

(c) Mammograms;

(d) Menopausal treatment services;

(e) Cancer screenings (except for pap smears or other similar screenings as identified in published billing instructions for family planning services); and

(f) All other reproductive health care, health care services or primary care services and prenatal care services.

(2) See chapter 388-530 WAC, Pharmacy services and chapter 388-531 WAC, Physician-related services for coverage of items and services not provided under this chapter.

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NEW SECTION
WAC 388-532-140   Reimbursement and payment limitations.   (1) MAA reimburses providers for covered family planning services using MAA's published fee schedules.

(2) For Healthy Options enrollees who have self-referred to an MAA-approved family planning provider outside their plan, all laboratory services must be billed through the family planning provider. See WAC 388-532-110 (2)(c), Provider requirements.

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FAMILY PLANNING ONLY PROGRAM
NEW SECTION
WAC 388-532-500   Purpose and scope.   The family planning only program provides an additional ten months of medical coverage for family planning services. This benefit follows the sixty-day postpartum coverage for women who received medical benefits during the pregnancy. Women receive this benefit regardless of how the pregnancy ends.

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NEW SECTION
WAC 388-532-510   Client eligibility.   A woman is eligible for family planning only (FPO) services if:

(1) She received medical benefits during her pregnancy; or

(2) She is determined eligible for a retroactive period covering the end of the pregnancy.

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NEW SECTION
WAC 388-532-520   Provider requirements.   In order to be reimbursed by MAA for family planning only services:

(1) Physicians and ARNPs must:

(a) Meet the requirements in chapter 388-502 WAC, Administration of medical programs--Provider rules; and

(b) Provide only those services that are within the scope of their licenses.

(2) Family planning providers must:

(a) Meet the requirements in chapter 388-502 WAC; and

(b) Provide medical information and education about Food and Drug Administration (FDA) approved prescription birth control methods and over-the-counter birth control supplies, to eligible clients who request such services.

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NEW SECTION
WAC 388-532-530   Covered services.   The following family planning only services are provided under this program:

(1) Gynecological exam as medically necessary.

(2) Food & Drug Administration (FDA) approved prescription contraception methods meeting the requirements of chapter 388-530 WAC, Pharmacy services.

(3) Over-the-counter (OTC) contraceptive, drugs and supplies (as described in chapter 388-530 WAC, Pharmacy services).

(4) Sterilization procedure that meets the requirements of WAC 388-531-1550(1), if it is:

(a) Requested by the client; and

(b) Performed in an appropriate setting for the procedure.

(5) Services such as laboratory exams, tests and procedures, and screening and treatment for sexually transmitted diseases-infections (STD-I) when:

(a) Performed in conjunction with a principal purpose diagnosis of family planning; and

(b) Required as part of the client's selected contraceptive method(s).

(6) Education on all FDA-approved contraceptives, natural family planning and abstinence.

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NEW SECTION
WAC 388-532-540   Noncovered services.   Noncovered services for the family planning only program are the same as shown in the previous section for family planning services. See WAC 388-532-130.

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NEW SECTION
WAC 388-532-550   Reimbursement and payment limitations.   (1) MAA limits reimbursement under the family planning only program to visits and services that have a principal purpose diagnosis of family planning. A qualified licensed medical practitioner must make the diagnosis.

(2) Except as noted in subsection (3) of this section, MAA reimburses providers for covered family planning only services using MAA's published fee schedules.

(3) MAA does not pay for inpatient services under the family planning only program rules. However, inpatient costs may be incurred as a result of complications arising from covered family planning services. Providers of inpatient services must submit a complete report of the circumstances and conditions that caused the need for the inpatient services. MAA will then make a determination of the circumstances and the potential payment sources (e.g., the family planning provider, the ancillary service provider(s) and/or MAA).

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