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Chapter 182-532 WAC

Last Update: 12/28/21

REPRODUCTIVE HEALTH/FAMILY PLANNING ONLY PROGRAMS

WAC Sections

DEFINITIONS
HTMLPDF182-532-001Reproductive health services—Definitions.
REPRODUCTIVE HEALTH SERVICES
HTMLPDF182-532-050Reproductive health services—General.
HTMLPDF182-532-100Reproductive health services—Eligibility.
HTMLPDF182-532-110Reproductive health services—Provider requirements.
HTMLPDF182-532-120Reproductive health services—Covered services.
HTMLPDF182-532-130Reproductive health services—Noncovered services.
HTMLPDF182-532-140Reproductive health services—Reimbursement and payment limitations.
FAMILY PLANNING ONLY PROGRAMS
HTMLPDF182-532-500Family planning only programs—Purpose.
HTMLPDF182-532-510Family planning only programs—Eligibility.
HTMLPDF182-532-520Family planning only programs—Provider requirements.
HTMLPDF182-532-530Family planning only programs—Covered services.
HTMLPDF182-532-550Family planning only programs—Payment limitations.
HTMLPDF182-532-560Family planning only programs—Documentation requirements.
HTMLPDF182-532-570Family planning only programs—Good cause exemption from billing third-party insurance.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-532-123Reproductive health—Other covered services for women. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-123, filed 7/25/13, effective 9/1/13.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-125Reproductive health—Covered services for men. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-125, filed 7/25/13, effective 9/1/13.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-505Family planning only program—Definitions. [WSR 11-14-075, recodified as § 182-532-505, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-505, filed 11/30/05, effective 12/31/05.] Repealed by WSR 13-16-008, filed 7/25/13, effective 9/1/13. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800.
182-532-533Family planning only program—Other covered services. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-533, filed 7/25/13, effective 9/1/13.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-540Family planning only program—Noncovered services. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-540, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-540, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-540, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-540, filed 2/6/04, effective 3/8/04.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-700TAKE CHARGE program—Purpose. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-700, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-700, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-700, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-700, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-710TAKE CHARGE program—Definitions. [WSR 11-14-075, recodified as § 182-532-710, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-710, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-710, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-710, filed 10/8/02, effective 11/8/02.] Repealed by WSR 13-16-008, filed 7/25/13, effective 9/1/13. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800.
182-532-720TAKE CHARGE program—Eligibility. [Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-01-013, § 182-532-720, filed 12/9/16, effective 1/9/17. Statutory Authority: RCW 41.05.021, 41.05.160 and P.L. 111-148. WSR 15-02-056, § 182-532-720, filed 1/5/15, effective 2/5/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-720, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-720, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-720, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-720, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-532-720, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-720, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-730TAKE CHARGE program—Provider requirements. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-730, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-730, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-532-730, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-730, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-730, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-730, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-740TAKE CHARGE program—Covered yearly exams for women. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-740, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-740, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-740, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-740, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-740, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-743TAKE CHARGE program—Other covered services for women. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-743, filed 7/25/13, effective 9/1/13.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-745TAKE CHARGE program—Covered services for men. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-745, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-745, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-745, filed 5/13/08, effective 6/13/08.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-750TAKE CHARGE program—Noncovered services. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-750, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-750, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-750, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-750, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-760TAKE CHARGE program—Documentation requirements. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-760, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-760, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-532-760, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-760, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-760, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-760, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-780TAKE CHARGE program—Reimbursement and payment limitations. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-780, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-780, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-780, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-780, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-780, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.
182-532-790TAKE CHARGE program—Good cause exemption from billing third party insurance. [Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-790, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-790, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-790, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-790, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-790, filed 10/8/02, effective 11/8/02.] Repealed by WSR 19-18-024, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act.

DEFINITIONS

PDF182-532-001

Reproductive health services—Definitions.

The following definitions and those found in 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 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 laboratory and diagnostic procedures that are covered under the client's respective agency program.
"Contraception" - Prevention of pregnancy through the use of contraceptive methods.
"Contraceptive" - 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.
"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 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 contraceptives that enable individuals to plan and space the number of their children and avoid unintended pregnancies.
"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 to be sold or dispensed. (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
(c) Pregnancy and reproductive health care.
"Reproductive health care services" - Any medical services or treatments, including pharmaceutical and preventive care service or treatments, directly involved in the reproductive system and its processes, functions, and organs involved in reproduction, in all stages of life. Reproductive health care services does not include infertility treatment.
"Reproductive system" - Includes, but is not limited to: Genitals, gonads, the uterus, ovaries, fallopian tubes, and breasts.
"Sexually transmitted infection (STI)" - A disease or infection acquired as a result of sexual contact.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-001, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-001, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-001, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-001, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-001, filed 2/6/04, effective 3/8/04.]


REPRODUCTIVE HEALTH SERVICES

PDF182-532-050

Reproductive health services—General.

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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-050, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-050, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-050, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-050, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-050, filed 2/6/04, effective 3/8/04. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-050, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. WSR 00-14-066, § 388-532-050, filed 7/5/00, effective 8/5/00.]


PDF182-532-100

Reproductive health services—Eligibility.

(1) The medicaid agency covers reproductive health 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 enrolled in 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, abortion, and sexually transmitted infection (STI) services from any agency-approved provider.
(3) A client who is age twenty-one or older may not self-refer outside their MCO for sterilizations.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-100, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-100, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-100, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-100, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-100, filed 2/6/04, effective 3/8/04. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-100, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. WSR 00-14-066, § 388-532-100, filed 7/5/00, effective 8/5/00.]


PDF182-532-110

Reproductive health services—Provider requirements.

To receive payment for reproductive health services, a provider must:
(1) Meet the requirements 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) Bill the agency according to the agency's published billing guides;
(4) Educate clients on Food and Drug Administration (FDA)-approved contraceptive methods and over-the-counter (OTC) contraceptive drugs, devices, and products, as well as related medical services;
(5) Provide medical services related to FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products upon request; and
(6) Supply or prescribe FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products upon request.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-110, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-110, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-110, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-110, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-110, filed 2/6/04, effective 3/8/04.]


PDF182-532-120

Reproductive health services—Covered services.

In addition to the services listed in WAC 182-531-0100, the medicaid agency covers all of the following 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 contraceptive methods, as described under WAC 182-530-2000;
(b) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence; and
(c) Sterilization procedures, as described under WAC 182-531-1550.
(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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-120, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-120, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-120, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-120, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-120, filed 2/6/04, effective 3/8/04.]


PDF182-532-130

Reproductive health services—Noncovered services.

Noncovered reproductive health services are described in WAC 182-501-0070 and 182-531-0150.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-130, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-130, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-130, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-130, filed 2/6/04, effective 3/8/04.]


PDF182-532-140

Reproductive health services—Reimbursement and payment limitations.

(1) The medicaid agency reimburses providers for covered reproductive health services using the medicaid agency's published fee schedules.
(2) 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).
[Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-140, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-140, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-140, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-140, filed 2/6/04, effective 3/8/04.]


FAMILY PLANNING ONLY PROGRAMS

PDF182-532-500

Family planning only programs—Purpose.

The purpose of family planning only programs is to provide family planning services to:
(1) Improve access to family planning and family planning-related services;
(2) Reduce unintended pregnancies; and
(3) Promote healthy intervals between pregnancies and births.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-500, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-500, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-500, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-500, filed 2/6/04, effective 3/8/04.]


PDF182-532-510

Family planning only programs—Eligibility.

To be eligible for one of the family planning only programs listed in this section, a client must meet the qualifications for that program. For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults 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 the Washington apple health for pregnant women program 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) Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);
(ii) Be a Washington state resident, as described under WAC 182-503-0520;
(iii) Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
(iv) Need family planning services; and
(v) Have been denied apple health coverage within the last thirty days, unless the applicant:
(A) Has made an informed choice to not apply for full-scope coverage, including family planning;
(B) Is age eighteen or younger and seeking services in confidence;
(C) Is a domestic violence victim who is seeking services in confidence; or
(D) 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) (v) 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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 § 211(47). WSR 20-21-024, § 182-532-510, filed 10/9/20, effective 11/9/20. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-510, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-510, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-510, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-510, filed 2/6/04, effective 3/8/04.]


PDF182-532-520

Family planning only programs—Provider requirements.

To be paid by the medicaid agency for services provided to clients eligible for family planning only programs, providers must:
(1) Meet the requirements 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) Bill the agency according to the agency's published billing guides;
(4) Educate clients on Food and Drug Administration (FDA)-approved contraceptive methods and over-the-counter (OTC) contraceptive drugs, devices, and products, as well as related medical services;
(5) Provide medical services related to FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically necessary;
(6) Supply or prescribe FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically appropriate; and
(7) Refer the client to available and affordable nonfamily planning primary care services, as needed.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-520, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-520, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-520, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-520, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-520, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-520, filed 2/6/04, effective 3/8/04.]


PDF182-532-530

Family planning only programs—Covered services.

The medicaid agency covers all of the following services:
(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 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
(c) Sterilization procedures, as described under WAC 182-531-1550.
(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.
(5) Human papillomavirus (HPV) vaccines.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-02-025, § 182-532-530, filed 12/28/21, effective 2/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-530, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-530, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-530, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-530, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-530, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-530, filed 2/6/04, effective 3/8/04.]


PDF182-532-550

Family planning only programs—Payment limitations.

(1) The medicaid agency limits 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, the client's chosen contraceptive method.
(2) The agency pays:
(a) Providers for covered family planning services using the agency's published fee schedules;
(b) For family planning pharmacy services, family planning laboratory services, and sterilization services using the agency's published fee schedules; and
(c) A dispensing fee only for contraceptive drugs purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC)
(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. 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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-550, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-550, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-550, filed 11/30/05, effective 12/31/05; WSR 04-05-011, § 388-532-550, filed 2/6/04, effective 3/8/04.]


PDF182-532-560

Family 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)
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-560, filed 8/28/19, effective 10/1/19.]


PDF182-532-570

Family 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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-570, filed 8/28/19, effective 10/1/19.]