WSR 19-14-062

PROPOSED RULES

HEALTH CARE AUTHORITY

[Filed June 28, 2019, 11:08 a.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 18-12-030 and 18-12-031.

Title of Rule and Other Identifying Information: Chapter 182-532 WAC, Reproductive health services.

Hearing Location(s): On August 6, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Apple Conference Room 127, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.

Date of Intended Adoption: Not sooner August 7, 2019.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by August 6, 2019.

Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email amber.lougheed@hca.wa.gov, by August 2, 2019.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is modifying the family planning only program and take charge program sections to: (1) Meet clinical standards, (2) align with current eligibility and provider enrollment policies, and (3) assure compliance with the recently approved federal extension of the Washington family planning only program (demonstration project) granted under the authority of section 1115(a) of the Social Security Act. The agency is modifying the reproductive health sections to meet clinical standards and align with current eligibility and provider enrollment policies.

Reasons Supporting Proposal: See purpose.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Statute Being Implemented: RCW 41.05.021, 41.05.160; Section 1115(a) of the Social Security Act.

Rule is necessary because of federal law, Section 1115(a) of the Social Security Act.

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Jason Crabbe, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-9563; Implementation and Enforcement: Jamie Teuteberg, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1668.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The revisions to this rule do not impose additional compliance costs or requirements on providers.

June 28, 2019

Wendy Barcus

Rules Coordinator

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-001Reproductive health services—Definitions.

The following definitions and those found in ((WAC 182-500-0005))chapter 182-500 WAC 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))preventive family planning visit" - 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))laboratory 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))Food and Drug Administration (FDA)-approved prescription and nonprescription methods, including devices, drugs, products, methods, or surgical interventions used to prevent pregnancy, as described in WAC 182-530-2000.

(("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 – Pregnancy related program" - The program that covers family planning only services for eligible clients for ten months following the sixty-day post pregnancy period.

"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.))covers family planning only services for eligible clients for twelve months from the date the agency determines eligibility. This program was formerly referred to as TAKE CHARGE.

"Family planning services" - Medically safe and effective medical care, educational services, ((and/or))and 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, devices, and products that do not require a prescription before they can be sold or dispensed and are approved by the Food and Drug Administration (FDA). (See WAC 182-530-1050((.)))

"Reproductive health" - The prevention and treatment of illness, disease, and disability related to the function of reproductive systems during all stages of life and includes:

(a) Related, appropriate, and medically necessary care;

(b) Education of clients in medically safe and effective methods of family planning; and

"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.)))

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-050Reproductive health services—((Purpose))General.

((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.))WAC 182-532-050 through 182-532-130 describe reproductive health services and related services covered by the medicaid agency. For maternity-related services, see chapter 182-533 WAC. For other related services, see chapter 182-531 WAC.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-100Reproductive health services—((Client))Eligibility.

(1) The medicaid agency covers ((limited)) reproductive health services ((for clients eligible for the following:

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

(b) Categorically needy program (CNP);

(d) Limited casualty program-medically needy program (LCP-MNP); and

(e) Alcohol and Drug Abuse Treatment and Support Act (ADATSA) services)), as described under WAC 182-532-120, for clients covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060.

(2) A client((s)) enrolled in ((a medicaid))an agency-contracted managed care organization (MCO) may self-refer outside their MCO for reproductive health care services including, but not limited to, family planning ((services (excluding sterilizations for clients twenty-one years of age or older))), abortion((s)), and sexually transmitted infection (STI) services((. These clients may seek services from any of the following:

(a) A medicaid agency-approved family planning provider;

(b) A medicaid agency-contracted local health department/STI clinic;

(d) A medicaid agency-contracted pharmacy))from any agency-approved provider.

(3) A client who is age twenty-one or older may not self-refer outside their MCO for sterilizations.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-110Reproductive health services—Provider requirements.

To ((be paid by the medicaid agency for reproductive health services provided to eligible clients, family planning providers, including licensed midwives,))receive payment for reproductive health services, a provider must:

(1) Meet the requirements ((in))under this chapter and chapters 182-501 and 182-502 WAC;

(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))Bill the agency according to the agency's published billing guides;

(4) Educate clients on Food and Drug Administration (FDA)-approved prescription ((birth control))contraceptive methods, as well as over-the-counter (OTC) ((birth control))contraceptive drugs, devices, and supplies, and related medical services;

(5) Provide medical services related to FDA-approved prescription ((birth control))contraceptive methods((,)) and OTC ((birth control))contraceptive drugs, devices, and supplies upon request; and

(6) Supply or prescribe FDA-approved prescription ((birth control))contraceptive methods((,)) and OTC ((birth control))contraceptive drugs, devices, and supplies upon request.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-120Reproductive health services—Covered ((yearly exams for women))services.

(((1) Along with))In addition to the services listed in WAC 182-531-0100, the medicaid agency covers ((one))all 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.

(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))reproductive health services:

(1) For a client capable of reproducing, one comprehensive preventive family planning visit once every twelve months, based on nationally recognized clinical guidelines, including:

(a) Sexually transmitted infection (STI) and cancer screenings; and

(b) Comprehensive and client-centered counseling, education, risk reduction, and initiation or management of contraceptive methods.

(2) Contraception, including:

(a) Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as described under WAC 182-530-2000;

(b) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence; and

(3) Cervical, breast, and prostate cancer screenings, according to nationally recognized clinical guidelines;

(4) STI screening, testing, and treatment, according to nationally recognized clinical guidelines;

(5) Human papillomavirus (HPV) immunization, administered according to the recommended schedule published by the Centers for Disease Control and Prevention (CDC);

(6) Diagnostic services, follow-up visits, imaging, and laboratory services related to the services listed under WAC 182-532-120; and

(7) Pregnancy-related services including:

(a) Maternity-related services, as described under chapter 182-533 WAC; and

(b) Abortion.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-130Reproductive health services—Noncovered services.

Noncovered reproductive health services are described in WAC 182-501-0070 and 182-531-0150.

FAMILY PLANNING ONLY PROGRAMS

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-500Family planning only programs—Purpose.

(((1))) The purpose of ((the)) family planning only programs is to provide family planning services to:

(((a) Increase the healthy intervals between pregnancies; and

(b)))(1) Improve access to family planning and family planning-related services;

(2) Reduce unintended pregnancies ((in women who received medical assistance coverage while pregnant.

(2) Women receive these services automatically, regardless of how or when the pregnancy ends. This ten-month coverage follows the medicaid agency's sixty-day postpregnancy coverage.

(3) Men are not eligible for the family planning only program)); and

(3) Promote healthy intervals between pregnancies and births.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-510Family planning only programs—((Client))Eligibility.

((A woman is eligible for family planning only services if:

(1) She received medical assistance coverage during her pregnancy; or

(2) She is determined eligible for a retroactive period covering the end of the pregnancy.))To be eligible for one of the family planning only programs listed in this section, a client must meet the qualifications for that program.

(1) Family planning only - Pregnancy related program.

(a) To be eligible for family planning only - Pregnancy related services, as defined in WAC 182-532-001, a client must be determined eligible for Washington apple health for pregnant clients during the pregnancy, or determined eligible for a retroactive period covering the end of a pregnancy. See WAC 182-505-0115.

(b) A client is automatically eligible for the family planning only - Pregnancy related program when the client's pregnancy ends.

(c) A client may apply for the family planning only program in subsection (2) of this section up to sixty days before the expiration of the family planning only - Pregnancy related program.

(2) Family planning only program.

(a) To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:

(i) Be a United States citizen, U.S. National, or "qualified alien" as described under WAC 182-503-0535;

(ii) Provide a valid Social Security number (SSN) or meet good cause criteria listed in WAC 182-503-0515(2);

(iii) Be a Washington state resident, as described under WAC 182-503-0520;

(iv) Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;

(v) Need family planning services; and

(vi) Have been denied apple health coverage through www.wahealthplanfinder.org within the last thirty days, unless the applicant:

(A) Is age eighteen and younger and seeking services in confidence;

(B) Is a domestic violence victim who is seeking services in confidence; or

(C) Has an income of one hundred fifty percent to two hundred sixty percent of the federal poverty level, as described in WAC 182-505-0100.

(b) A client is not eligible for family planning only medical if the client is:

(i) Pregnant;

(ii) Sterilized;

(iii) Covered under another apple health program that includes family planning services; or

(iv) Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (a)(vi) of this subsection.

(c) A client may reapply for coverage under the family planning only program up to sixty days before the expiration of the twelve-month coverage period. The agency does not limit the number of times a client may reapply for coverage.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-520Family planning only programs—Provider requirements.

To be ((reimbursed))paid by the medicaid agency for services provided to clients eligible for ((the)) family planning only programs, ((family planning)) providers must:

(1) Meet the requirements ((in))under this chapter and chapters 182-501 and 182-502 WAC;

(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))Bill the agency according to the agency's published billing guides;

(5) Provide medical services related to FDA-approved prescription ((birth control))contraceptive methods((,)) and OTC ((birth control))contraceptive drugs, devices, and supplies as medically necessary;

(6) Supply or prescribe FDA-approved prescription ((birth control))contraceptive methods((,)) and OTC ((birth control))contraceptive drugs, devices, and supplies as medically appropriate; and

(7) Refer the client to available and affordable nonfamily planning primary care services, as needed.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-530Family planning only programs—Covered ((yearly exams))services.

(((1))) The medicaid agency covers ((one))all 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.

(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)):

(1) One comprehensive preventive family planning visit once every twelve months, based on nationally recognized clinical guidelines. This visit must have a primary focus and diagnosis of family planning and include counseling, education, risk reduction, and initiation or management of contraceptive methods;

(2) Assessment and management of family planning or contraceptive problems, when medically necessary;

(3) Contraception, including:

(a) Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as described under WAC 182-530-2000;

(b) Education and supplies for Federal Drug Administration (FDA)-approved contraceptive, natural family planning, and abstinence; and

(4) The following services, when appropriate, during a visit focused on family planning:

(a) Pregnancy testing;

(b) Cervical cancer screening, according to nationally recognized clinical guidelines;

(c) Gonorrhea and chlamydia screening and treatment for clients age thirteen through twenty-five, according to nationally recognized clinical guidelines;

(d) Syphilis screening and treatment for clients who have an increased risk for syphilis, according to nationally recognized guidelines; and

(e) Sexually transmitted infection (STI) screening, testing, and treatment, when medically indicated by symptoms or report of exposure, and medically necessary for the client's safe and effective use of their chosen contraceptive method.

AMENDATORY SECTION(Amending WSR 13-16-008, filed 7/25/13, effective 9/1/13)

WAC 182-532-550Family planning only programs—((Reimbursement and))Payment limitations.

(1) The medicaid agency limits ((reimbursement))payment under the family planning only programs to 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 use, or continue to use, ((her))the client's chosen contraceptive method.

(2) The ((medicaid)) agency ((reimburses))pays:

(a) Providers for covered family planning ((only)) services using the agency's published fee schedules((.

(3)));

(b) For family planning pharmacy services, family planning ((lab))laboratory 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))using the agency's published fee schedules; and

(c) 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))(3) The agency does not pay for inpatient services under the family planning only programs, except for complications arising from covered family planning services.

(4) The agency requires providers to:

(a) Meet the timely billing requirements of WAC 182-502-0150; and

(b) Seek timely reimbursement from a third party when a client has available third-party resources, as described under WAC 182-501-0200. ((The))Exceptions to this requirement are described under WAC 182-501-0200 (2) and (3) and 182-532-570.

(5) Services provided to family planning clients by federally qualified health centers (FQHCs), rural health centers (RHCs), and Indian health care providers (IHCP) do not qualify for encounter or enhanced rates.

NEW SECTION

WAC 182-532-560Family planning only programs—Documentation requirements.

In addition to the requirements in WAC 182-502-0020, providers must document the following in the client's medical record:

(1) Primary focus and diagnosis of the visit is family planning related;

(2) Contraceptive methods discussed;

(3) Plan for use of a contraceptive method, or the reason and plan for no contraceptive method;

(4) Education, counseling, and risk reduction with sufficient detail that allows for follow-up;

(5) Referrals to, or from, other providers; and

(6) If applicable, a copy of the completed consent form for sterilization. (See WAC 182-531-1550)

NEW SECTION

WAC 182-532-570Family planning only programs—Good cause exemption from billing third-party insurance.

(1) For the purposes of this section, "good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party:

(a) Routinely sends written, verbal, or electronic communications, as defined in RCW 48.43.505, to the third-party subscriber and that subscriber is someone other than the client; or

(b) Requires the client to use a primary care provider who is likely to report the client's request for family planning services to the subscriber.

(2) Clients eligible for family planning only programs may request an exemption from the requirement to bill third-party insurance due to "good cause" if they are:

(a) Eighteen years of age or younger and seeking services in confidence; or

(b) Domestic violence victims and seeking services in confidence.

REPEALER

The following sections of the Washington Administrative Code are repealed:

WAC 182-532-123	Reproductive health—Other covered services for women.
WAC 182-532-125	Reproductive health—Covered services for men.
WAC 182-532-533	Family planning only program—Other covered services.
WAC 182-532-540	Family planning only program—Noncovered services.
WAC 182-532-700	TAKE CHARGE program—Purpose.
WAC 182-532-720	TAKE CHARGE program—Eligibility.
WAC 182-532-730	TAKE CHARGE program—Provider requirements.
WAC 182-532-740	TAKE CHARGE program—Covered yearly exams for women.
WAC 182-532-743	TAKE CHARGE program—Other covered services for women.
WAC 182-532-745	TAKE CHARGE program—Covered services for men.
WAC 182-532-750	TAKE CHARGE program—Noncovered services.
WAC 182-532-760	TAKE CHARGE program—Documentation requirements.
WAC 182-532-780	TAKE CHARGE program—Reimbursement and payment limitations.
WAC 182-532-790	TAKE CHARGE program—Good cause exemption from billing third party insurance.