WSR 13-16-008 PERMANENT RULES HEALTH CARE AUTHORITY (Medicaid Program) [Filed July 25, 2013, 10:16 a.m., effective September 1, 2013] Effective Date of Rule: September 1, 2013.
Purpose: The rules add language to clarify, update and ensure clear and consistent policies for family planning providers, and amend TAKE CHARGE rule sections on eligibility (WAC 182-532-700 through 182-532-790) so they comply with the new federal waiver for the TAKE CHARGE medicaid program. Changes to other sections in chapter 182-532 WAC include:
The related sterilization section, WAC 182-531-1550, is amended by: Adding a requirement for national board certification for becoming an approved hysteroscopic sterilization provider; clarifying other rule requirements; moving hysterectomy requirements from WAC 182-531-1550 to WAC 182-531-0150 and 182-531-0200 for a more suitable fit; and making housekeeping changes due to the HCA merger.
Citation of Existing Rules Affected by this Order: Repealing WAC 182-532-505 and 182-532-710; and amending WAC 182-531-0150, 182-531-0200, 182-531-1550, 182-532-001, 182-532-050, 182-532-100, 182-532-110, 182-532-120, 182-532-130, 182-532-140, 182-532-500, 182-532-510, 182-532-520, 182-532-530, 182-532-540, 182-532-550, 182-532-700, 182-532-720, 182-532-730, 182-532-740, 182-532-745, 182-532-750, 182-532-760, 182-532-780, and 182-532-790.
Statutory Authority for Adoption: RCW 41.05.021.
Other Authority: RCW 74.09.520, 74.09.657, 74.09.659, 74.09.800.
Adopted under notice filed as WSR 13-11-069 on May 16, 2013.
Changes Other than Editing from Proposed to Adopted Version: Added "follows the guidelines of a nationally recognized protocol" to the clinical breast examination and pelvic examination in reproductive health, family planning only, and TAKE CHARGE yearly exams for women under covered services (WAC 182-532-120, 182-532-530 and 182-532-740.) Clarified to indicate that family planning providers or agency-contracted local health department STI clinics under contract with the agency's managed care plans must abide by their contract regarding lab services needed by clients for that plan (WAC 182-532-540(6)).
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.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 4, Amended 25, Repealed 2.
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 4, Amended 25, Repealed 2.
Date Adopted: July 25, 2013.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-0150 Noncovered physician-related and health care professional services—General and administrative.
(1) Except as provided in WAC ((388-531-0100)) 182-531-0100 and subsection (2) of this section, the ((department)) medicaid agency does not cover the following: (a) Acupuncture, massage, or massage therapy; (b) Any service specifically excluded by statute; (c) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation; (d) Hysterectomy performed solely for the purpose of sterilization; (e) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness; (((e))) (f) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC ((388-501-0165)) 182-501-0165; (((f))) (g) Hair transplantation; (((g))) (h) Marital counseling or sex therapy; (((h))) (i) More costly services when the ((department)) medicaid agency determines that less costly, equally effective services are available; (((i))) (j) Vision-related services as follows: (i) Services for cosmetic purposes only; (ii) Group vision screening for eyeglasses; and (iii) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens correction. This refractive surgery does not include intraocular lens implantation following cataract surgery. (((j))) (k) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC ((388-531-1750)) 182-531-1750; (((k))) (l) Physician-supplied medication, except those drugs administered by the physician in the physician's office; (((l))) (m) Physical examinations or routine checkups, except as provided in WAC ((388-531-0100)) 182-531-0100; (((m))) (n) Foot care, unless the client meets criteria and conditions outlined in WAC ((388-531-1300)) 182-531-1300, as follows: (i) Routine foot care, such as but not limited to: (A) Treatment of tinea pedis; (B) Cutting or removing warts, corns and calluses; and (C) Trimming, cutting, clipping, or debriding of nails. (ii) Nonroutine foot care, such as, but not limited to treatment of: (A) Flat feet; (B) High arches (cavus foot); (C) Onychomycosis; (D) Bunions and tailor's bunion (hallux valgus); (E) Hallux malleus; (F) Equinus deformity of foot, acquired; (G) Cavovarus deformity, acquired; (H) Adult acquired flatfoot (metatarsus adductus or pes planus); (I) Hallux limitus. (iii) Any other service performed in the absence of localized illness, injury, or symptoms involving the foot; (((n))) (o) Except as provided in WAC ((388-531-1600)) 182-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services. (((o))) (p) Nonmedical equipment; (((p))) (q) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas; (((q))) (r) Bilateral cochlear implantation; and (((r))) (s) Routine or nonemergency medical and surgical dental services provided by a doctor of dental medicine or dental surgery for clients twenty one years of age and older, except for clients of the ((division of)) developmental disabilities administration in the department of social and health services. (2) The ((department)) medicaid agency covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following: (a) The EPSDT program; (b) A medicaid program for qualified medicare beneficiaries (QMBs); or (c) A waiver program.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-0200 Physician-related and health care professional services requiring prior authorization.
(1) The ((department)) medicaid agency requires prior authorization for certain services. Prior authorization includes expedited prior authorization (EPA) and limitation extension (LE). See WAC ((388-501-0165)) 182-501-0165. (2) The EPA process is designed to eliminate the need for telephone prior authorization for selected admissions and procedures. (a) The provider must create an authorization number using the process explained in the ((department's)) medicaid agency's physician-related billing instructions. (b) Upon request, the provider must provide supporting clinical documentation to the ((department)) medicaid agency showing how the authorization number was created. (c) Selected nonemergency admissions to contract hospitals require EPA. These are identified in the ((department)) medicaid agency billing instructions. (d) Procedures allowing expedited prior authorization include, but are not limited to, the following: (i) Reduction mammoplasties/mastectomy for gynecomastia; (ii) Strabismus surgery for clients eighteen years of age and older; (iii) Meningococcal vaccine; (iv) Placement of drug eluting stent and device; (v) Cochlear implants for clients twenty years of age and younger; (vi) Hyperbaric oxygen therapy; (vii) Visual exam/refraction for clients twenty-one years of age and older; (viii) Blepharoplasties; and (ix) Neuropsychological testing for clients sixteen years of age and older. (3) The ((department)) medicaid agency evaluates new technologies under the procedures in WAC ((388-531-0550)) 182-531-0550. These require prior authorization. (4) Prior authorization is required for the following: (a) Abdominoplasty; (b) All inpatient hospital stays for acute physical medicine and rehabilitation (PM&R); (c) Unilateral cochlear implants for clients twenty years of age and younger (refer to WAC ((388-531-0375)) 182-531-0375); (d) Diagnosis and treatment of eating disorders for clients twenty-one years of age and older; (e) Osteopathic manipulative therapy in excess of the ((department's)) medicaid agency's published limits; (f) Panniculectomy; (g) Bariatric surgery (see WAC ((388-531-1600)) 182-531-1600); and (h) Vagus nerve stimulator insertion, which also: (i) For coverage, must be performed in an inpatient or outpatient hospital facility; and (ii) For reimbursement, must have the invoice attached to the claim. (i) Osseointegrated/bone anchored hearing aids (BAHA) for clients twenty years of age and younger; (j) Removal or repair of previously implanted BAHA or cochlear device for clients twenty one years of age and older when medically necessary. (5) All hysterectomies performed for medical reasons may require prior authorization, as explained in subsection (2) of this section. (a) Hysterectomies may be performed without prior authorization in either of the following circumstances: (i) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or (ii) A hysterectomy is needed due to trauma. (b) The agency reimburses all attending providers for a hysterectomy procedure only when the provider submits an accurately completed agency-approved consent form with the claim for reimbursement. (6) The ((department)) medicaid agency may require a second opinion and/or consultation before authorizing any elective surgical procedure. (((6))) (7) Children six years of age and younger do not require authorization for hospitalization.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-1550 Sterilization physician-related services.
(1) For purposes of this section, sterilization is any medical procedure, treatment, or operation for the purpose of rendering a client permanently incapable of reproducing. ((A hysterectomy is a surgical procedure or operation for the purpose of removing the uterus.)) Hysterectomy results in sterilization((, but the department does not cover hysterectomy performed)) and is not covered by the medicaid agency solely for that purpose. ((Both hysterectomy and sterilization procedures require the use of specific consent forms. See subsections (10), (11) and (12) of this section for additional coverage criteria for hysteroscopic sterilizations.)) (See WAC 182-531-0150 and 182-531-0200 for more information about hysterectomies.) STERILIZATION (2) The ((department)) medicaid agency covers sterilization when all of the following apply: (a) The client is at least eighteen years of age at the time an agency-approved consent form is signed; (b) The client is a mentally competent individual; (c) The client participates in a medical assistance program (see WAC 182-501-0060); (d) The client has voluntarily given informed consent ((in accordance with all the requirements defined in this subsection)); and (((d) At least thirty days, but not more than one hundred eighty days, have passed between the date the client gave informed consent and the date of the sterilization. (3))) (e) The date the client signed a sterilization consent is at least thirty days and not more than one hundred eighty days before the date of the sterilization procedure. (3) Any medicaid provider who is licensed to do sterilizations within their scope of practice may provide vasectomies and tubal ligations to any medicaid client. (See subsections (10), (11), and (12) of this section for additional qualifications of providers performing hysteroscopic sterilizations.) (4) The ((department does not require the thirty-day waiting period, but does)) medicaid agency requires at least a seventy-two hour waiting period((,)) rather than the usual thirty-day waiting period for sterilization in either of the following circumstances: (a) At the time of a premature delivery((,)) when the client gave consent at least thirty days before the expected date of delivery. (The expected date of delivery must be documented on the consent form((;)).) (b) For emergency abdominal surgery((,)). (The nature of the emergency must be described on the consent form.) (((4))) (5) The ((department)) medicaid agency waives the thirty-day consent waiting period for sterilization when the client requests that sterilization be performed at the time of delivery((,)) and completes a sterilization consent form. One of the following circumstances must apply: (a) The client became eligible for medical assistance during the last month of pregnancy; (b) The client did not obtain medical care until the last month of pregnancy; or (c) The client was a substance abuser during pregnancy, but is not using alcohol or illegal drugs at the time of delivery. (((5))) (6) The ((department)) medicaid agency does not accept informed consent obtained when the client is ((in any of the following conditions)): (a) In labor or childbirth; (b) In the process of seeking to obtain or obtaining an abortion; or (c) Under the influence of alcohol or other substances, including pain medications for labor and delivery, that affects the client's state of awareness. (((6))) (7) The ((department)) medicaid agency has certain consent requirements that the provider must meet before the ((department)) agency reimburses sterilization of ((a mentally incompetent or)) an institutionalized client or a client with mental incompetence. The ((department)) agency requires both of the following: (a) A court order, which includes both a statement that the client is to be sterilized, and the name of the client's legal guardian who will be giving consent for the sterilization; and (b) A sterilization consent form signed by the legal guardian, sent to the ((department)) agency at least thirty days ((prior to)) before the procedure. (((7))) (8) The ((department)) medicaid agency reimburses epidural anesthesia in excess of the six-hour limit for ((sterilization procedures that are performed in conjunction with or immediately following a delivery. The provider cannot bill separately for BAUs for the sterilization procedure. The department determines total billable units by: (a) Adding the time for the sterilization procedure to the time for the delivery; and (b) Determining the total billable units by adding together the delivery BAUs, the delivery time, and the sterilization time. (8) The physician identified in the "consent to sterilization" section of the DSHS-approved sterilization consent form must be the same physician who completes the "physician's statement" section and performs the sterilization procedure. If a different physician performs the sterilization procedure, the client must sign and date a new consent form at the time of the procedure that indicates the name of the physician performing the operation under the "consent for sterilization" section. This modified consent must be attached to the original consent form when the provider bills the department)) deliveries if sterilization procedures are performed in conjunction with or immediately following a delivery. (a) For reimbursement, anesthesia time for sterilization is added to the time for the delivery when the two procedures are performed during the same operative session. (b) If the sterilization and delivery are performed during different operative sessions, the anesthesia time is calculated separately. (9) The ((department)) medicaid agency reimburses all attending providers for the sterilization procedure only when the provider submits an ((appropriate, completed DSHS-approved)) agency-approved and complete consent form with the claim for reimbursement. (See subsections (10), (11), and (12) of this section for additional coverage criteria for hysteroscopic sterilizations.) (a) The physician must complete and sign the physician statement on the consent form within thirty days of the sterilization procedure. (b) The ((department)) agency reimburses attending providers after the procedure is completed. hysteroscopic sterilizations (10) The ((department)) medicaid agency pays for hysteroscopic sterilizations when the following additional criteria are met: (a) A ((department-approved)) device covered by the agency is used((;)). (b) The procedure is predominately performed in a clinical setting, such as a physician's office, without general anesthesia and without the use of a surgical suite; and is covered according to the corresponding ((department)) agency fee schedule((;)). (c) If determining that it is medically necessary to perform the procedure in an inpatient rather than outpatient setting, a provider must submit clinical notes with the claim, documenting the medical necessity. (d) The client provides informed consent for the procedure ((in accordance with this section; and (d))). (e) The hysteroscopic sterilization is performed by ((a department-approved)) an approved provider who: (i) Has a core provider agreement with the ((department)) agency; (ii) Is nationally board certified in obstetrics and gynecology (OB-GYN); (iii) Is privileged at a licensed hospital to do hysteroscopies; (iv) Has successfully completed the manufacturer's training for the device covered by the agency; (v) Has successfully performed a minimum of twenty hysteroscopies; and (vi) Has established screening and follow-up protocols for clients being considered for hysteroscopic sterilization. (((12))) (11) To become ((a department-approved provider)) approved for hysteroscopic sterilizations, interested providers must send the ((department)) medicaid agency-approved vendor, identified in the agency's billing instructions, the following: (a) Documentation of successful completion of the manufacturer's training; (b) Documentation demonstrating privilege at a licensed hospital to perform hysteroscopies; (c) Documentation attesting to having successfully performed twenty or more hysteroscopies; ((and)) (d) Evidence of valid National Board Certification; and (e) Office protocols for screening and follow-up. ((HYSTERECTOMY (13) Hysterectomies performed for medical reasons may require expedited prior authorization as explained in WAC 388-531-0200(2). (14) The department reimburses hysterectomy without prior authorization in either of the following circumstances: (a) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or (b) The client is forty-six years of age or older. (15) The department reimburses all attending providers for the hysterectomy procedure only when the provider submits an appropriate, completed DSHS-approved consent form with the claim for reimbursement. If a prior authorization number is necessary for the procedure, it must be on the claim. The department reimburses after the procedure is completed.)) (12) The provider will not be paid to perform the hysteroscopic procedure until the medicaid agency sends written approval to the provider.
((REPRODUCTIVE HEALTH SERVICES)) DEFINITIONS
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-001 Reproductive health services—((Purpose)) Definitions.
((The department of social and health services (DSHS) defines reproductive health services as those services that: (1) Assist clients to avoid illness, disease, and disability related to reproductive health; (2) Provide related and appropriate, medically necessary care when needed; and (3) Assist clients to make informed decisions about using medically safe and effective methods of family planning.)) The following definitions and those found in WAC 182-500-0005 apply to this chapter. 340B dispensing fee - The medicaid agency's established fee paid to a registered and medicaid-participating 340B drug program provider under the public health service (PHS) act for expenses involved in acquiring, storing and dispensing prescription drugs or drug-containing devices (see WAC 182-530-7900). A dispensing fee is not paid for nondrug items, devices or supplies (see WAC 182-530-7050). "Complication" - A condition occurring subsequent to and directly arising from the family planning services received under the rules of this chapter. "Comprehensive prevention visit for family planning" - For the purposes of this program, a comprehensive, preventive, contraceptive visit that includes evaluation and management of an individual, such as: Age appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and labs and diagnostic procedures that are covered under the client's respective medicaid agency program. These services may only be provided by and paid to TAKE CHARGE providers. "Contraception" - Prevention of pregnancy through the use of contraceptive methods. "Contraceptive" - A device, drug, product, method, or surgical intervention used to prevent pregnancy. "Delayed pelvic protocol" - The practice of allowing a woman to postpone a pelvic exam during a contraceptive visit to facilitate the start or continuation of a hormonal contraceptive method. "Education, counseling and risk reduction intervention (ECRR)" - Client-centered education and counseling services designed to strengthen decision-making skills and support a client's safe and effective use of a chosen contraceptive method. For women, ECRR is part of the comprehensive prevention visit for family planning. For men, ECRR is a stand-alone service for those men who seek family planning services and whose partners are at moderate to high risk of unintended pregnancy. "Family planning only program" - The program that provides an additional ten months of family planning services to eligible women at the end of their pregnancy. This benefit follows the sixty-day postpregnancy coverage for women who received medical assistance benefits during the pregnancy. "Family planning provider" - For this chapter, a physician or physician's assistant, advanced registered nurse practitioner (ARNP), or clinic that, in addition to meeting requirements in chapter 182-502 WAC, is approved by the medicaid agency to provide family planning services to eligible clients as described in this chapter. "Family planning services" - Medically safe and effective medical care, educational services, and/or contraceptives that enable individuals to plan and space the number of their children and avoid unintended pregnancies. "Medicaid agency" - Health care authority. "Natural family planning" (also known as fertility awareness method) - Methods to identify the fertile days of the menstrual cycle and avoid unintended pregnancies, such as observing, recording, and interpreting the natural signs and symptoms associated with the menstrual cycle. "Over-the-counter (OTC)" - Drugs that do not require a prescription before they can be sold or dispensed. (See WAC 182-530-1050.) "Sexually transmitted infection (STI)" - A disease or infection acquired as a result of sexual contact. "TAKE CHARGE" - The medicaid agency's demonstration and research program approved by the federal government under a medicaid program waiver to provide family planning services. "TAKE CHARGE provider" - A family planning provider who has a TAKE CHARGE agreement to provide TAKE CHARGE family planning services to eligible clients under the terms of the federally approved medicaid waiver for the TAKE CHARGE program. (See WAC 182-532-730 for provider requirements.)
REPRODUCTIVE HEALTH SERVICES
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-050 Reproductive health services—((Definitions)) Purpose.
((The following definitions and those found in WAC 388-500-005, Medical definitions, apply to this chapter. "Complication"—A condition occurring subsequent to and directly arising from the family planning services received under the rules of this chapter. "Comprehensive family planning preventive medicine visit"—For the purposes of this program, is a comprehensive, preventive, contraceptive visit which includes: • An age and gender appropriate history and examination offered to female medicaid clients who are at-risk for unintended pregnancies; • Education and counseling for risk reduction (ECRR) regarding the prevention of unintended pregnancy; and • For family planning only and TAKE CHARGE clients, routine gonorrhea and chlamydia testing for women thirteen through twenty-five years of age only. This preventive visit may be billed only once every twelve months, per client, by a department-contracted TAKE CHARGE provider and only for female clients needing contraception. "Contraception"—Preventing pregnancy through the use of contraceptives. "Contraceptive"—A device, drug, product, method, or surgical intervention used to prevent pregnancy. "Delayed pelvic protocol"—The practice of allowing a woman to postpone a pelvic exam during a contraceptive visit to facilitate initiation or continuation of a hormonal contraceptive method. "Department"—The department of social and health services. "Department-approved family planning provider"—A physician, advanced registered nurse practitioner (ARNP), or clinic that has: • Agreed to the requirements of WAC 388-532-110; • Signed a core provider agreement with the department; • Been assigned a unique family planning provider number by the department; and • Agreed to bill for family planning laboratory services provided to clients enrolled in a department-managed care plan through an independent laboratory certified through the Clinical Laboratory Improvements Act (CLIA). "Family planning services"—Medically safe and effective medical care, educational services, and/or contraceptives that enable individuals to plan and space the number of children and avoid unintended pregnancies. "Medical identification card"—The document the department uses to identify a client's eligibility for a medical program. "Natural family planning"—(Also known as fertility awareness method) means methods such as observing, recording, and interpreting the natural signs and symptoms associated with the menstrual cycle to identify the fertile days of the menstrual cycle and avoid unintended pregnancies. "Over-the-counter (OTC)"—See WAC 388-530-1050 for definition. "Sexually transmitted disease infection (STD-I)"—A disease or infection acquired as a result of sexual contact.)) The medicaid agency defines reproductive health services as those services that: (1) Assist clients to avoid illness, disease, and disability related to reproductive health; (2) Provide related, appropriate, and medically necessary care when needed; and (3) Assist clients to make informed decisions about using medically safe and effective methods of family planning.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-100 Reproductive health services—Client eligibility.
(1) The ((department)) medicaid agency covers limited reproductive health services for clients eligible for the following: (a) ((State)) Children's health insurance program (((SCHIP)) CHIP); (b) Categorically needy program (CNP); (c) ((General assistance unemployable (GAU) program;)) Medical care services (MCS) program; (d) Limited casualty program-medically needy program (LCP-MNP); and (e) Alcohol and Drug Abuse Treatment and Support Act (ADATSA) services. (2) Clients enrolled in a ((department)) medicaid agency-contracted managed care organization (MCO) may self-refer outside their MCO for family planning services (excluding sterilizations for clients twenty-one years of age or older), abortions, and ((STD-I)) sexually transmitted infection (STI) services ((to)). These clients may seek services from any of the following: (a) A ((department-approved)) medicaid agency-approved family planning provider; (b) A ((department-contracted)) medicaid agency-contracted local health department/((STD-I)) STI clinic; (c) A ((department-contracted)) medicaid agency-contracted provider for abortion services; or (d) A ((department-contracted)) medicaid agency-contracted pharmacy ((for: (i) Over-the-counter contraceptive drugs and supplies, including emergency contraception; and (ii) Contraceptives and STD-I related prescriptions from a department-approved family planning provider or department-contracted local health department/STD-I clinic.))
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-110 Reproductive health services—Provider requirements.
To be paid by the ((department)) medicaid agency for reproductive health services provided to eligible clients, ((physicians, ARNPs, licensed midwives, and department-approved)) family planning providers, including licensed midwives, must: (1) Meet the requirements in chapter ((388-502)) 182-502 WAC((, Administration of medical programs—Provider rules)); (2) Provide only those services that are within the scope of their licenses; (3) Comply with the required general medicaid agency and reproductive health provider policies, procedures, and administrative practices as detailed in the agency's billing instructions; (4) Educate clients on Food and Drug Administration (FDA)-approved prescription birth control methods ((and)), over-the-counter (OTC) birth control drugs and supplies, and related medical services; (((4))) (5) Provide medical services related to FDA-approved prescription birth control methods, and OTC birth control drugs and supplies upon request; and (((5))) (6) Supply or prescribe FDA-approved prescription birth control methods, and OTC birth control drugs and supplies upon request((; (6) Refer the client to an appropriate provider if unable to meet the requirements of subsections (3), (4), and (5) of this section[;] and (7) Refer the client to available and affordable nonfamily planning primary care services, as needed)).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-120 Reproductive health—Covered ((services)) yearly exams for women.
((In addition to those services listed in WAC 388-531-0100 Physician-related services, the department covers the following reproductive health services: (1) Services for women: (a) The department covers one of the following per client, per year as medically necessary: (i) A gynecological examination, billed by a provider other than a TAKE CHARGE provider, which may include a cervical and vaginal cancer screening examination when medically necessary; or (ii) One comprehensive family planning preventive medicine visit, billable by a TAKE CHARGE provider only. Under a delayed pelvic protocol, the comprehensive family planning preventive medicine visit may be split into two visits, per client, per year. The comprehensive family planning preventive medicine visit must be: (A) Provided by one or more of the following TAKE CHARGE trained providers: (I) A physician or physician's assistant (PA); (II) An advanced registered nurse practitioner (ARNP); or (III) A registered nurse (RN), licensed practical nurse (LPN), a trained and experienced health educator, medical assistant, or certified nursing assistant when used for assisting and augmenting the clinicians listed in (I) and (II) in subsection (1) of this section. (B) Documented in the client's chart with detailed information that allows for a well-informed follow-up visit. (b) Food and Drug Administration (FDA) approved prescription contraception methods as identified in chapter 388-530 WAC, Pharmacy services. (c) Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies without a prescription when the department determines it necessary for client access and safety as described in chapter 388-530 WAC, Prescription drugs (outpatient). (d) Sterilization procedures that meet the requirements of WAC 388-531-1550, if: (i) Requested by the client; and (ii) Performed in an appropriate setting for the procedure. (e) Screening and treatment for sexually transmitted diseases-infections (STD-I), including laboratory tests and procedures. (f) Education and supplies for FDA-approved contraceptives, natural family planning and abstinence. (g) Mammograms for clients forty years of age and older, once per year; (h) Colposcopy and related medically necessary follow-up services; (i) Maternity-related services as described in chapter 388-533 WAC; and (j) Abortion. (2) Services for men: (a) Office visits where the primary focus and diagnosis is contraceptive management and/or there is a medical concern; (b) Over-the-counter (OTC) contraceptives, drugs and supplies (as described in chapter 388-530 WAC, Prescription drugs (outpatient)). (c) Sterilization procedures that meet the requirements of WAC 388-531-1550(1), if: (i) Requested by the client; and (ii) Performed in an appropriate setting for the procedure. (d) Screening and treatment for sexually transmitted diseases-infections (STD-I), including laboratory tests and procedures. (e) Education and supplies for FDA-approved contraceptives, natural family planning and abstinence. (f) Prostate cancer screenings for men, once per year, when medically necessary.)) (1) Along with services listed in WAC 182-531-0100, the medicaid agency covers one of the following yearly exams per client per year: (a) A cervical, vaginal, and breast cancer screening exam; or (b) A comprehensive prevention visit for family planning. (Under a delayed pelvic protocol, the comprehensive prevention visit for family planning may be split into two visits, per client, per year.) (2) The cervical, vaginal, and breast cancer screening examination: (a) Must follow the guidelines of a nationally recognized protocol; and (b) May be billed by a provider other than a TAKE CHARGE provider. (3) The comprehensive prevention visit for family planning: (a) Must be provided by one or more qualified TAKE CHARGE providers. (See WAC 182-532-730.) (b) Must include: (i) A clinical breast examination and pelvic examination that follows the guidelines of a nationally recognized protocol; and (ii) Client-centered counseling that incorporates risk factor reduction for unintended pregnancy and anticipatory guidance about the advantages and disadvantages of all contraceptive methods. (c) May include a pap smear according to current, nationally recognized clinical guidelines. (d) Must be documented in the client's chart with detailed information that allows for a well-informed follow-up visit. (e) Must be billed by a TAKE CHARGE provider only.
NEW SECTION
WAC 182-532-123 Reproductive health—Other covered services for women.
Other reproductive health services covered for women include: (1) Office visits when medically necessary; (2) Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as identified in chapter 182-530 WAC; (3) Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies, as described in chapter 182-530 WAC; (4) Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures; (5) Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures; (6) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence; (7) Mammograms for clients forty years of age and older once per year, and for clients thirty-nine years of age and younger with prior authorization; (8) Colposcopy and related medically necessary follow-up services; (9) Maternity-related services as described in chapter 182-533 WAC; and (10) Abortion.
NEW SECTION
WAC 182-532-125 Reproductive health—Covered services for men.
In addition to those services listed in WAC 182-531-0100, the medicaid agency covers the following reproductive health services for men: (1) Office visits where there is a medical concern, including contraceptive and vasectomy counseling; (2) Over-the-counter (OTC) contraceptive supplies as described in chapter 182-530 WAC; (3) Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures; (4) Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures; (5) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence; (6) Prostate cancer screenings for men, once per year, when medically necessary; and (7) Diagnostic mammograms for men when medically necessary.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-130 Reproductive health—Noncovered services.
Noncovered reproductive health services are ((the same as shown)) described in WAC ((388-531-0150, Noncovered physician-related services—General and administrative)) 182-531-0150.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-140 Reproductive health services—Reimbursement and payment limitations.
(1) The ((department)) medicaid agency reimburses providers for covered reproductive health services using the ((department's)) medicaid agency's published fee schedules. (2) ((When a client enrolled in a department-approved managed care plan self-refers outside the plan to either a department-approved family planning provider or a department-contracted local health department STD-I clinic for family planning or STD-I services, all laboratory services must be billed through the family planning provider. (3) When a client enrolled in a department managed care plan obtains family planning or STD-I services from a department-approved family planning provider or a department-contracted local health department/STD-I clinic which has a contract with the managed care plan, those services must be billed directly to the managed care plan.)) Family planning pharmacy services, family planning lab services, and sterilization services are reimbursed by the medicaid agency under the rules and fee schedules applicable to these specific programs. (3) The medicaid agency pays a dispensing fee only for contraceptive drugs that are purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC.) (4) Family planning providers under contract with the agency's managed care plans must directly bill the plans for family planning or STI services received by clients enrolled in the plan. (5) Family planning providers not under contract with the agency's managed care plans must bill using fee for service when providing services to managed care clients who self-refer outside their plans. (6) Family planning providers or agency-contracted local health department STI clinics under contract with the agency's managed care plans must abide by their contract regarding lab services needed by clients from that plan. (7) Family planning providers or agency-contracted local health department STI clinics not under contract with the agency's managed care plans must pay a lab directly for services provided to clients who self-refer outside of their managed care plan. Providers then must bill the medicaid agency for reimbursement for lab services. (a) Labs must be certified through the Clinical Laboratory Improvements Act (CLIA). (b) Documentation of current CLIA certification must be kept on file. (8) Under WAC 182-501-0200, the medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources. The exceptions to this requirement are described under WAC 182-501-0200 (2) and (3).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-500 Family planning only program—Purpose.
(1) The purpose of the family planning only program is to provide family planning services ((at the end of a pregnancy to women who received medical assistance benefits during their pregnancy. The primary goal of the family planning only program is to prevent an unintended, subsequent pregnancy)) to: (a) Increase the healthy intervals between pregnancies; and (b) Reduce unintended pregnancies in women who received medical assistance coverage while pregnant. (2) Women receive ((this benefit)) these services automatically, regardless of how or when the pregnancy ends. This ten-month ((benefit)) coverage follows the ((department's)) medicaid agency's sixty-day postpregnancy coverage. (3) Men are not eligible for the family planning only program.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-510 Family planning only program—Client eligibility.
A woman is eligible for family planning only services if: (1) She received medical assistance ((benefits)) coverage during her pregnancy; or (2) She is determined eligible for a retroactive period ((as defined in WAC 388-500-0005)) covering the end of the pregnancy.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-520 Family planning only program—Provider requirements.
To be reimbursed by the ((department)) medicaid agency for services provided to clients eligible for the family planning only program, ((physicians, ARNPs, and/or department-approved)) family planning providers must: (1) Meet the requirements in chapter ((388-502)) 182-502 WAC((, Administration of medical programs—Provider rules)); (2) Provide only those services that are within the scope of their licenses; (3) Comply with the required general medicaid agency and family planning only provider policies, procedures, and administrative practices as detailed in the agency's billing instructions; (4) Educate clients on Food and Drug Administration (FDA)-approved prescription birth control methods ((and)), over-the-counter (OTC) birth control drugs and supplies, and related medical services; (((4))) (5) Provide medical services related to FDA-approved prescription birth control methods, and OTC birth control drugs and supplies ((upon request)) as medically necessary; (((5))) (6) Supply or prescribe FDA-approved prescription birth control methods, and OTC birth control drugs and supplies ((upon request)) as medically appropriate; and (((6) Refer the client to an appropriate provider if unable to meet the requirements of subsections (3), (4), and (5) of this section; and)) (7) Refer the client to available and affordable nonfamily planning primary care services, as needed.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-530 Family planning only program—Covered ((services)) yearly exams.
((The department covers the following services under the family planning only program: (1) One of the following, per client, per year as medically necessary: (a) One comprehensive family planning preventive medicine visit billable by a TAKE CHARGE provider only. Under a delayed pelvic protocol, the comprehensive family planning preventive medicine visit may be split into two visits, per client, per year. The comprehensive family planning preventive medicine visit must be: (I) Provided by one or more of the following TAKE CHARGE trained providers: (A) Physician or physician's assistant (PA); (B) An advanced registered nurse practitioner (ARNP); or (C) A registered nurse (RN), licensed practical nurse (LPN), a trained and experienced health educator, medical assistant, or certified nursing assistant when used for assisting and augmenting the clinicians listed in subsection (A) and (B) of this section. (II) Documented in the client's chart with detailed information that allows for a well-informed follow-up visit; or (b) A gynecological examination, billed by a provider other than a TAKE CHARGE provider, which may include a cervical and vaginal cancer screening examination, one per year when it is: (i) Provided according to the current standard of care; and (ii) Conducted at the time of an office visit with a primary focus and diagnosis of family planning. (2) An office visit directly related to a family planning problem, when medically necessary. (3) Food and Drug Administration (FDA) approved prescription contraception methods meeting the requirements of chapter 388-530 WAC, Prescription drugs (outpatient). (4) Over-the-counter (OTC) family-planning drugs, devices, and drug-related supplies without a prescription when the department determines it necessary for client access and safety (as described in chapter 388-530 WAC, Prescription drugs (outpatient)). (5) Sterilization procedure that meets the requirements of WAC 388-531-1550, if it is: (a) Requested by the client; and (b) Performed in an appropriate setting for the procedure. (6) Screening and treatment for sexually transmitted diseases-infections (STD-I), including laboratory test and procedures only when the screening and treatment is: (a) For chlamydia and gonorrhea as part of the comprehensive family planning preventive medicine visit for women thirteen to twenty-five years of age; or (b) Performed in conjunction with an office visit that has a primary focus and diagnosis of family planning; and (c) Medically necessary for the client to safely, effectively, and successfully use, or to continue to use, her chosen contraceptive method. (7) Education and supplies for FDA-approved contraceptives, natural family planning and abstinence.)) (1) The medicaid agency covers one of the following services per client per year, as medically necessary: (a) A cervical, vaginal, and breast cancer screening exam; or (b) A comprehensive prevention visit for family planning. (Under a delayed pelvic protocol, the comprehensive prevention visit for family planning may be split into two visits, per client, per year.) (2) The cervical, vaginal, and breast cancer screening exam: (a) Must be: (i) Provided following the guidelines of a nationally recognized protocol; and (ii) Conducted at the time of an office visit with a primary focus and diagnosis of family planning. (b) May be billed by a provider other than a TAKE CHARGE provider. (3) The comprehensive prevention visit for family planning: (a) Must be provided by one or more qualified TAKE CHARGE trained providers. (See WAC 182-532-730.) (b) Must include: (i) A clinical breast examination and pelvic examination that follows the guidelines of a nationally recognized protocol; and (ii) Client-centered counseling that incorporates risk factor reduction for unintended pregnancy and anticipatory guidance about the advantages and disadvantages of all contraceptive methods. (c) May include: (i) A pap smear according to current, nationally recognized clinical guidelines; and (ii) For women ages thirteen through twenty-five, routine gonorrhea and chlamydia testing and treatment. (d) Must be documented in the client's chart with detailed information that allows for a well-informed follow-up visit. (e) Must be billed by a TAKE CHARGE provider only.
NEW SECTION
WAC 182-532-533 Family planning only program—Other covered services.
Other family planning only services covered for women may include all the following: (1) An office visit directly related to a family planning problem, when medically necessary. (2) Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as identified in chapter 182-530 WAC. (3) Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies, as described in chapter 182-530 WAC. (4) Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures. (5) Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures, only when the screening and treatment are: (a) For chlamydia and gonorrhea as part of the comprehensive prevention visit for family planning for women ages thirteen through twenty-five; or (b) Part of an office visit that has a primary focus and diagnosis of family planning, and is medically necessary for the client's safe and effective use of her chosen contraceptive method. (6) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-540 Family planning only program—Noncovered services.
(1) Medical services are not covered under the family planning only program unless those services are: (((1))) (a) Performed in relation to a primary focus and diagnosis of family planning; and (((2) Are)) (b) Medically necessary for ((the)) a client to safely((,)) and effectively((, and successfully)) use, or continue to use, her chosen contraceptive method. (2) The medicaid agency does not cover inpatient services under the family planning only program except for complications arising from covered family planning services. For approval of exceptions, providers of inpatient services must submit a report to the medicaid agency, detailing the circumstances and conditions that required inpatient services. (See WAC 182-501-0160.)
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-550 Family planning only program—Reimbursement and payment limitations.
(1) The ((department)) medicaid agency limits reimbursement under the family planning only program to ((visits and)) services that: (a) Have a primary focus and diagnosis of family planning as determined by a qualified licensed medical practitioner; and (b) Are medically necessary for the client to safely((,)) and effectively((, and successfully)) use, or continue to use, her chosen contraceptive method. (2) The ((department)) medicaid agency reimburses providers for covered family planning only services using the ((department's)) agency's published fee schedules. (3) ((The department does not cover inpatient services under the family planning only program. However, inpatient charges may be incurred as a result of complications arising directly from a covered family planning service. If this happens, providers of family planning-related inpatient services that are not otherwise covered by third parties or other medical assistance programs must submit to the department a complete report of the circumstances and conditions that caused the need for the inpatient services.)) Family planning pharmacy services, family planning lab services, and sterilization services are reimbursed by the medicaid agency under the rules and fee schedules applicable to these specific programs. (4) The medicaid agency pays a dispensing fee only for contraceptive drugs that are purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC.) (5) Under WAC 182-501-0200, the medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources. The exceptions to this requirement are described under WAC 182-501-0200 (2) and (3).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-700 TAKE CHARGE program—Purpose.
TAKE CHARGE is a family planning demonstration and research program approved by the federal government under a medicaid ((program)) waiver. The purpose of ((the)) TAKE CHARGE ((program)) is to ((make family planning services available to men and women with incomes at or below two hundred percent of the federal poverty level. See WAC 388-532-710 for a definition of TAKE CHARGE)) reduce unintended pregnancies and lower the expenditures for medicaid-paid births.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-720 TAKE CHARGE program—Eligibility.
(1) The TAKE CHARGE program is for men and women. To be eligible for the TAKE CHARGE program, an applicant must: (a) Be a United States citizen, U.S. National, or "qualified alien" as described in ((chapter 388-424)) WAC 182-503-0530, and ((provide)) give proof of citizenship or qualified alien status((,)) and identity upon request from the medicaid agency; (b) Provide a valid Social Security number (SSN); (c) Be a resident of the state of Washington as described in WAC 388-468-0005; (((c))) (d) Have an income at or below two hundred fifty percent of the federal poverty level as described in WAC ((388-478-0075)) 182-505-0100; (((d))) (e) Need family planning services; (((e))) (f) Apply voluntarily for family planning services with a TAKE CHARGE provider; and (((f))) (g) Not be ((currently)) covered currently through another medical assistance program for family planning ((or have any health insurance that covers family planning, except as provided in WAC 388-530-790)). (2) A client who is pregnant or sterilized is not eligible for TAKE CHARGE. (3) A client is authorized for TAKE CHARGE coverage for one year from the date the ((department)) medicaid agency determines eligibility ((or for the duration of the demonstration and research program, whichever is shorter, as long as the criteria in subsection (1) and (2) of this section continue to be met)). Upon reapplication for TAKE CHARGE by the client, the ((department)) medicaid agency may renew the coverage for an additional period((s)) of up to one year ((each)), or for the duration of the ((demonstration and research program)) waiver, whichever is shorter.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-730 TAKE CHARGE program—Provider requirements.
(1) A TAKE CHARGE provider must: (a) Be a ((department-approved)) family planning provider ((as described in WAC 388-532-050)), which may include a registered nurse (RN), a licensed practical nurse (LPN), a trained and experienced health educator, a medical assistant, or a certified nursing assistant who assists a family planning provider; (b) Meet the requirements in chapter 182-502 WAC; (c) Provide only those services that are within the scope of their licenses; (d) Sign and comply with the ((supplemental)) TAKE CHARGE agreement to participate in the TAKE CHARGE demonstration and research program according to the ((department's)) medicaid agency's TAKE CHARGE program guidelines; (((c))) (e) Comply with the required general medicaid agency and TAKE CHARGE provider policies, procedures, and administrative practices as detailed in the agency's billing instructions; (f) Participate in the ((department's)) medicaid agency's specialized training for the TAKE CHARGE demonstration and research program ((prior to)) before providing TAKE CHARGE services((.)); ((Providers must)) (g) Document that each individual responsible for providing TAKE CHARGE services is trained on all aspects of the TAKE CHARGE program; (((d) Comply with the required general department and TAKE CHARGE provider policies, procedures, and administrative practices as detailed in the department's billing instructions and provide referral information to clients regarding available and affordable nonfamily planning primary care services; (e))) (h) If requested by the ((department)) medicaid agency, participate in the research and evaluation component of the TAKE CHARGE demonstration and research program((.)); (((f))) (i) If requested by the client, forward the client's services card and ((TAKE CHARGE brochure)) any related information to the ((client)) client's preferred address within ((seven)) five working days of receipt ((unless otherwise requested in writing by the client)); (((g))) (j) Inform the client of his or her right to seek services from any TAKE CHARGE provider within the state; and (((h))) (k) Refer the client to available and affordable nonfamily planning primary care services, as needed. (2) ((Department)) Medicaid agency providers who are not TAKE CHARGE providers, (((e.g.,)) such as pharmacies, ((laboratories)) labs, and surgeons performing sterilization procedures) ((who are not TAKE CHARGE providers may furnish family planning ancillary TAKE CHARGE services, as defined in this chapter, to eligible TAKE CHARGE clients. The department reimburses for these services under the rules and fee schedules applicable to the specific services provided under the department's other programs)) may give family planning pharmacy services, family planning lab services, and sterilization services to TAKE CHARGE clients.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-740 TAKE CHARGE program—Covered ((services)) yearly exams for women.
((The department covers the following TAKE CHARGE services for women: (1) One session of application assistance per client, per year; (2) Food and Drug Administration (FDA) approved prescription and nonprescription contraceptives as provided in chapter 388-530 WAC, Prescription drugs (outpatient); (3) Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies without a prescription when the department determines it necessary for client access and safety (as described in chapter 388-530 WAC, Prescription drugs (outpatient)); (4) One comprehensive family planning preventive medicine visit billable by a TAKE CHARGE provider only. Under a delayed pelvic protocol, the comprehensive family planning preventive medicine visit may be split into two visits, per client, per year. The comprehensive family planning preventive medicine visit must be: (a) Provided by one or more of the following TAKE CHARGE trained providers: (i) Physician or physician's assistant (PA); (ii) An advanced registered nurse practitioner (ARNP); or (iii) A registered nurse (RN), licensed practical nurse (LPN), a trained and experienced health educator, medical assistant, or certified nursing assistant when used for assisting and augmenting the above listed clinicians. (b) Documented in the client's chart with detailed information that allows for a well-informed follow-up visit. (5) Sterilization procedure that meets the requirements of WAC 388-531-1550, if the service is: (i) Requested by the TAKE CHARGE client; and (ii) Performed in an appropriate setting for the procedure. (6) Screening and treatment for sexually transmitted diseases-infections (STD-I), including laboratory tests and procedures, only when the screening and treatment is: (a) For chlamydia and gonorrhea as part of the comprehensive family planning preventive medicine visit for women thirteen to twenty-five years of age; or (b) Performed in conjunction with an office visit that has a primary focus and diagnosis of family planning; and (c) Medically necessary for the client to safely, effectively, and successfully use, or continue to use, his or her chosen contraceptive method. (7) Education and supplies for FDA-approved contraceptives, natural family planning and abstinence. (8) An office visit directly related to a family planning problem, when medically necessary.)) (1) The medicaid agency covers one of the following services per client per year, as medically necessary: (a) A cervical, vaginal, and breast cancer screening exam; or (b) A comprehensive prevention visit for family planning. (Under a delayed pelvic protocol, the comprehensive prevention visit for family planning may be split into two visits, per client, per year.) (2) The cervical, vaginal and breast cancer screening exam must be: (a) Provided following the guidelines of a nationally recognized protocol; (b) Conducted at the time of an office visit with a primary focus and diagnosis of family planning; and (c) Performed by a TAKE CHARGE provider. (3) The comprehensive prevention visit for family planning: (a) Must be provided by one or more TAKE CHARGE-trained providers. (See WAC 182-532-730.) (b) Must include: (i) A clinical breast examination and pelvic examination that follows the guidelines of a nationally recognized protocol; and (ii) Client-centered counseling that incorporates risk factor reduction for unintended pregnancy and anticipatory guidance about the advantages and disadvantages of all contraceptive methods. (c) May include: (i) A pap smear according to current, nationally recognized clinical guidelines; and (ii) For women ages thirteen through twenty-five, routine gonorrhea and chlamydia testing and treatment. (d) Must be documented in the client's chart with detailed information that allows for a well-informed follow-up visit. (e) Must be billed by a TAKE CHARGE provider only.
NEW SECTION
WAC 182-532-743 TAKE CHARGE program—Other covered services for women.
Other TAKE CHARGE services covered for women may include all the following: (1) An office visit directly related to a family planning problem, when medically necessary. (2) Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as provided in chapter 182-530 WAC. (3) Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies, as described in chapter 182-530 WAC. (4) Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures. (5) Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures, only when the screening and treatment are: (a) For chlamydia and gonorrhea as part of the comprehensive prevention visit for family planning for women thirteen through twenty-five years of age; or (b) Part of an office visit that has a primary focus of family planning and is medically necessary for the client's safe and effective use of her chosen contraceptive method. (6) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-745 TAKE CHARGE program—Covered services for men.
The ((department)) medicaid agency covers all the following TAKE CHARGE services for men: (1) ((One session of application assistance per client, per year; (2))) Over-the-counter (OTC) ((contraceptives, drugs, and)) contraceptive supplies ((()), as described in chapter ((388-530)) 182-530 WAC((, Prescription Drugs (Outpatient)); (3) Sterilization procedure that meets the requirements of WAC 388-531-1550, if the service is: (a) Requested by the TAKE CHARGE client; and (b) Performed in an appropriate setting for the procedure. (4))). (2) Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures. (3) Screening and treatment for sexually transmitted ((diseases-))infections (((STD-I)) STI), including ((laboratory)) lab tests and procedures, only when the screening and treatment ((is)) are related to((,)) and medically necessary for((,)) a sterilization procedure. (((5))) (4) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence. (((6))) (5) One education and counseling session for risk reduction (ECRR) per client((,)) every twelve months for those male clients whose female partners are at moderate to high risk for unintended pregnancy. ECRR must be: (a) Provided by one or more ((of the following)) TAKE CHARGE- trained providers((: (i) Physician or physician's assistant (PA); (ii) An advanced registered nurse practitioner (ARNP); or (iii) A registered nurse (RN), licensed practical nurse (LPN), a trained and experienced health educator, medical assistant, or certified nursing assistant when used for assisting and augmenting the clinicians listed in subsection (i) and (ii) of this section)) (see WAC 182-532-730); and (b) Documented in the client's chart with detailed information that allows for a well-informed follow-up visit.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-750 TAKE CHARGE program—Noncovered services.
((The department does not cover the following medical services under the TAKE CHARGE program: (1) Abortions and other pregnancy-related services; and (2) Any other medical services, unless those services are:)) (1) Medical services are not covered under the TAKE CHARGE program unless those services are: (a) Performed in relation to a primary focus and diagnosis of family planning; and (b) Medically necessary for ((the)) clients to safely((,)) and effectively((, and successfully)) use, or continue to use, ((his or her)) their chosen contraceptive methods. (2) The medicaid agency does not cover inpatient services under the TAKE CHARGE program except for complications arising from covered family planning services. For approval of exceptions, providers of inpatient services must submit a report to the medicaid agency, detailing the circumstances and conditions that required inpatient services. (See WAC 182-501-0160.)
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-760 TAKE CHARGE program—Documentation requirements.
In addition to the documentation requirements in WAC ((388-502-0020)) 182-502-0020, TAKE CHARGE providers must keep the following records: (1) ((TAKE CHARGE application form(s); (2))) The signed supplemental TAKE CHARGE agreement to participate in the TAKE CHARGE program; (((3))) (2) Documentation of the ((department's)) medicaid agency's specialized TAKE CHARGE training and/or in-house ((in-service)) TAKE CHARGE training for each individual responsible for providing TAKE CHARGE((.)); (((4))) (3) TAKE CHARGE application form(s), along with supporting documentation if provided; (4) Chart notes ((that reflect)) reflecting that the primary focus and diagnosis of the visit was family planning; (5) Contraceptive methods discussed with the client; (6) Notes on any discussions of emergency contraception and needed prescription(s); (7) The client's plan for the contraceptive method to be used, or the reason for no contraceptive method and plan; (8) Documentation of the education, counseling and risk reduction (ECRR) service, if provided, with sufficient detail that allows for follow((-)) up; (9) Documentation of referrals to or from other providers; (10) A form signed by the client authorizing the release of information for referral purposes, as necessary; (11) The client's written and signed consent requesting that his or her services card be sent to the TAKE CHARGE provider's office to protect confidentiality; and (12) ((A copy of the client's picture identification; (13) A copy of the documentation used to establish United States citizenship or legal permanent residency; and (14))) If applicable, a copy of the completed ((department)) medicaid agency-approved sterilization consent form (((DSHS 13-364 - available for download at http://www.dshs.wa.gov/msa/forms/eforms.html) (see WAC 388-531-1550))). (See WAC 182-531-1550 for more details about sterilization and the consent form.)
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-780 TAKE CHARGE program—Reimbursement and payment limitations.
(1) The ((department)) medicaid agency limits reimbursement under the TAKE CHARGE program to those services that: (a) Have a primary focus and diagnosis of family planning as determined by a qualified licensed medical practitioner; and (b) Are medically necessary for ((the)) clients to safely((,)) and effectively((, and successfully)) use, or continue to use, ((his or her)) their chosen contraceptive methods. (2) The ((department)) medicaid agency reimburses TAKE CHARGE providers for covered TAKE CHARGE services ((according to)) using the ((department's)) agency's published ((TAKE CHARGE)) fee schedule. (3) Providers without signed TAKE CHARGE agreements are reimbursed by the medicaid agency only for clinic visits that are related to sterilization or complications from a birth control method. (4) Family planning pharmacy services, family planning lab services, and sterilization services are reimbursed by the medicaid agency under the rules and fee schedules applicable to these specific programs. (5) The medicaid agency pays a dispensing fee only for contraceptive drugs that are purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC.) (6) The ((department)) medicaid agency limits reimbursement for TAKE CHARGE research and evaluation activities to selected research sites. (((4))) (7) Federally qualified health centers (FQHCs), rural health centers (RHCs), and Indian health providers who ((choose to become)) are TAKE CHARGE providers must bill the ((department)) medicaid agency for TAKE CHARGE services without regard to: (a) Their special rates and fee schedules((. The department does not reimburse FQHCs, RHCs or Indian health providers under the encounter rate structure for TAKE CHARGE services. (5))); or (b) The encounter rate structure. (8) The ((department)) medicaid agency requires TAKE CHARGE providers to meet the billing requirements of WAC ((388-502-0150 (billing time limits). In addition, all final billings and billing adjustments related to the TAKE CHARGE program must be completed no later than two years after the demonstration and research program terminates. The department will not accept new billings or billing adjustments that increase expenditures for the TAKE CHARGE program after the cut-off date. (6) The department does not cover inpatient services under the TAKE CHARGE program. However, inpatient charges may be incurred as a result of complications arising directly from a covered TAKE CHARGE service. If this happens, providers of TAKE CHARGE related inpatient services that are not otherwise covered by third parties or other medical assistance programs must submit to the department a complete report of the circumstances and conditions that caused the need for inpatient services for the department to consider payment under WAC 388-501-0165)) 182-502-0150. (((7) The department)) (9) Under WAC 182-501-0200, the medicaid agency requires a provider ((under WAC 388-501-0200)) to seek timely reimbursement from a third party when a client has available third-party resources. The exceptions to this requirement are described under WAC ((388-501-0200)) 182-501-0200 (2) and (3) and ((388-532-790)) 182-532-790.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-532-790 TAKE CHARGE program—Good cause exemption from billing third party insurance.
(((1) TAKE CHARGE applicants who are eighteen years of age or younger and depend on their parents' medical insurance, or individuals who are domestic violence victims who depend on their spouses or another's health insurance may request an exemption, due to "good cause," from the eligibility restrictions in WAC 388-532-720 (1)(f) and from the use of available third party family planning coverage. Under the TAKE CHARGE program, "good cause" means that use of the third party coverage would violate his or her confidentiality because the third party: (a) Routinely or randomly sends verification of services to the third party subscriber and that subscriber is other than the applicant; and/or (b) Requires the applicant to use a primary care provider who is likely to report the applicant's request for family planning services to the subscriber. (2) If subsection (1)(a) or (1)(b) of this section applies, the applicant is eligible for TAKE CHARGE without regard to the available third party family planning coverage.)) (1) Under the TAKE CHARGE program, two groups of clients may request an exemption from the medicaid requirement to bill third-party insurance due to "good cause." The two groups are: (a) TAKE CHARGE applicants who: (i) Are eighteen years of age or younger; (ii) Are covered under their parents' health insurance; and (iii) Do not want their parents to know that they are seeking and/or receiving family planning services. (b) Individuals who are domestic violence victims and are covered under the perpetrator's health insurance. (2) "Good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party: (a) Routinely sends verification of services to the third-party subscriber and that subscriber is someone other than the applicant; and/or (b) Requires the applicant to use a primary care provider who is likely to report the applicant's request for family planning services to the subscriber.
REPEALER
The following sections of the Washington Administrative Code are repealed:
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