WSR 03-12-067

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEATH SERVICES
(Medical Assistance Administration)

[ Filed June 2, 2003, 4:48 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 02-09-048.

Title of Rule: Chapter 388-532 WAC, Family planning services: WAC 388-532-001 Purpose (new section), 388-532-050 Definitions (amended), 388-532-100 Client eligibility (amended and renamed), 388-532-110 Provider requirements (new section), 388-532-120 Covered services (new section), 388-532-130 Noncovered services (new section), and 388-532-140 Reimbursement and payment limitations (new section).

Family planning only program, new sections WAC 388-532-500 Purpose and scope, 388-532-510 Client eligibility, 388-532-520 Provider requirements, 388-532-530 Covered services, 388-532-540 Noncovered services, and 388-532-550 Reimbursement and payment limitations.

Purpose: Regulatory improvement under Executive Order 97-02, which requires MAA to review its rules and to improve them by clarifying and simplifying where possible.

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

Statute Being Implemented: RCW 74.09.800.

Summary: The proposed changes will reorganize information within the chapter and add language to identify: MAA clients who are eligible for family planning services; provider requirements; covered family planning services; reimbursement limitations; and rules for family planning only program.

Reasons Supporting Proposal: Regulatory improvement. The current rules are very brief and do not include definitions, or information on eligibility, reimbursement limitations, or the family planning only program.

Name of Agency Personnel Responsible for Drafting: Myra Davis, MAA, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1306; Implementation and Enforcement: Beth L. Brenner, MAA, East 649 Woodland Square Loop, Olympia, WA 98504-5530, (360) 725-1652.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The proposal replaces brief, general language in chapter 388-532 WAC with a more complete description of MAA's family planning services. The proposal adds definitions, information on eligibility, services, reimbursement limitations and the family planning only program.

Proposal Changes the Following Existing Rules: Current language is replaced and information is reorganized. There are no substantive changes to program operations.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed changes do not impose any new costs or reduce any reimbursement to small business.

RCW 34.05.328 applies to this rule adoption. The proposed rule change meets the definition of a significant legislative rule. A determination of the probable costs and benefits is available from the person(s) listed above.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on July 8, 2003, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact DSHS Rules Consultant by July 1, 2003, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensFH@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, e-mail swensfh@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on July 8, 2003.

Date of Intended Adoption: Not sooner than July 9, 2003.

May 29, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3214.3FAMILY PLANNING SERVICES
NEW SECTION
WAC 388-532-001   Purpose.   This chapter contains medical assistance administration (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. Defined words and phrases are bolded when they first appear in the text.

"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 by preventing conception.

"Contraceptive" means a device, drug or product that prevents conception.

"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.

"Family planning services" means medical care, contraceptive supplies and educational services which enable individuals to plan and space the number of children by using contraception 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) General assistance unemployable (GAU) No out-of-state care; and

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

(2) Healthy Options enrollees may self-refer outside their plan (HMO) or primary care case manager 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.   (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 clinic 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) 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 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 natural family planning and abstinence.

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

(1) Infertility treatment services;

(2) Abortions;

(3) Mammograms;

(4) Menopausal treatment services;

(5) Cancer screenings (except for pap smears); and

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

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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 post-partum coverage for women who received medical benefits for 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) 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.   (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 clinic providers must:

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

(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 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) Testing 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 in 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 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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