Chapter 182-532 WAC

Last Update: 12/9/16

REPRODUCTIVE HEALTH/FAMILY PLANNING ONLY/TAKE CHARGE

WAC Sections

DEFINITIONS
182-532-001Reproductive health services—Definitions.
REPRODUCTIVE HEALTH SERVICES
182-532-050Reproductive health services—Purpose.
182-532-100Reproductive health services—Client eligibility.
182-532-110Reproductive health services—Provider requirements.
182-532-120Reproductive health—Covered yearly exams for women.
182-532-123Reproductive health—Other covered services for women.
182-532-125Reproductive health—Covered services for men.
182-532-130Reproductive health—Noncovered services.
182-532-140Reproductive health services—Reimbursement and payment limitations.
FAMILY PLANNING ONLY PROGRAM
182-532-500Family planning only program—Purpose.
182-532-510Family planning only program—Client eligibility.
182-532-520Family planning only program—Provider requirements.
182-532-530Family planning only program—Covered yearly exams.
182-532-533Family planning only program—Other covered services.
182-532-540Family planning only program—Noncovered services.
182-532-550Family planning only program—Reimbursement and payment limitations.
TAKE CHARGE PROGRAM
182-532-700TAKE CHARGE program—Purpose.
182-532-720TAKE CHARGE program—Eligibility.
182-532-730TAKE CHARGE program—Provider requirements.
182-532-740TAKE CHARGE program—Covered yearly exams for women.
182-532-743TAKE CHARGE program—Other covered services for women.
182-532-745TAKE CHARGE program—Covered services for men.
182-532-750TAKE CHARGE program—Noncovered services.
182-532-760TAKE CHARGE program—Documentation requirements.
182-532-780TAKE CHARGE program—Reimbursement and payment limitations.
182-532-790TAKE CHARGE program—Good cause exemption from billing third party insurance.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
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 Repealed by WSR 13-16-008, filed 7/25/13, effective 9/1/13.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.
182-532-710TAKE 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.


182-532-001
Reproductive health services—Definitions.

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.)
[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.]



182-532-050
Reproductive health services—Purpose.

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.
[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.]



182-532-100
Reproductive 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);
(c) 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 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 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;
(c) A medicaid agency-contracted provider for abortion services; or
(d) A medicaid agency-contracted pharmacy
[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.]



182-532-110
Reproductive 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, must:
(1) Meet the requirements in chapter 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;
(4) Educate clients on Food and Drug Administration (FDA)-approved prescription birth control methods, over-the-counter (OTC) birth control drugs and supplies, and related medical services;
(5) Provide medical services related to FDA-approved prescription birth control methods, and OTC birth control drugs and supplies upon request; and
(6) Supply or prescribe FDA-approved prescription birth control methods, and OTC birth control drugs and supplies upon request.
[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.]



182-532-120
Reproductive health—Covered yearly exams for women.

(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.
[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.]



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.
[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.]



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.
[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.]



182-532-130
Reproductive health—Noncovered services.

Noncovered reproductive health services are described in WAC 182-531-0150.
[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.]



182-532-140
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.]



182-532-500
Family planning only program—Purpose.

(1) The purpose of the family planning only program is to provide family planning services 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 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.
[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.]



182-532-510
Family planning only program—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.
[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.]



182-532-520
Family planning only program—Provider requirements.

To be reimbursed by the medicaid agency for services provided to clients eligible for the family planning only program, family planning providers must:
(1) Meet the requirements in chapter 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;
(4) Educate clients on Food and Drug Administration (FDA)-approved prescription birth control methods, over-the-counter (OTC) birth control drugs and supplies, and related medical services;
(5) Provide medical services related to FDA-approved prescription birth control methods, and OTC birth control drugs and supplies as medically necessary;
(6) Supply or prescribe FDA-approved prescription birth control methods, and OTC birth control drugs and supplies 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, 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.]



182-532-530
Family planning only program—Covered yearly exams.

(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.
[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.]



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.
[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.]



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:
(a) Performed in relation to a primary focus and diagnosis of family planning; and
(b) Medically necessary for a client to safely and effectively 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.)
[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.]



182-532-550
Family planning only program—Reimbursement and payment limitations.

(1) The medicaid agency limits reimbursement under the family planning only program 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 chosen contraceptive method.
(2) The medicaid agency reimburses providers for covered family planning only services using the agency's published fee schedules.
(3) 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).
[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.]



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 waiver. The purpose of TAKE CHARGE is to reduce unintended pregnancies and lower the expenditures for medicaid-paid births.
[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.]



182-532-720
TAKE CHARGE programEligibility.

(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 WAC 182-503-0530, and 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 182-503-0520;
(d) Have an income at or below two hundred sixty percent of the federal poverty level as described in WAC 182-505-0100;
(e) Need family planning services;
(f) Have applied for categorically needy coverage, unless the applicant:
(i) Is a domestic violence victim who is covered under the alleged perpetrator's health insurance;
(ii) Is under eighteen years of age and is seeking confidential services; or
(iii) Has an income between one hundred fifty percent and two hundred sixty percent (inclusive) of the federal poverty level.
(g) Apply voluntarily for family planning services with a TAKE CHARGE provider; and
(h) Not be covered currently through another Washington apple health program for family planning. If categorically needy coverage is approved for a TAKE CHARGE recipient, the individual will be enrolled in the categorically needy program.
(2) An applicant who is pregnant or sterilized is not eligible for TAKE CHARGE.
(3) An applicant who has concurrent coverage under a creditable health insurance policy as defined in WAC 182-12-109 is not eligible for TAKE CHARGE unless the applicant is seeking confidential services and is either under nineteen years old or is a domestic violence victim who is covered under the perpetrator's insurance.
(4) A client is authorized for TAKE CHARGE coverage for one year from the date the medicaid agency determines eligibility, or for the duration of the waiver, whichever is shorter. Upon reapplication for TAKE CHARGE by the client, the medicaid agency may renew the coverage for an additional period of up to one year, or for the duration of the waiver, whichever is shorter.
[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.]



182-532-730
TAKE CHARGE program—Provider requirements.

(1) A TAKE CHARGE provider must:
(a) Be a family planning provider, 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 TAKE CHARGE agreement to participate in the TAKE CHARGE demonstration and research program according to the medicaid agency's TAKE CHARGE program guidelines;
(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 medicaid agency's specialized training for the TAKE CHARGE demonstration and research program before providing TAKE CHARGE services;
(g) Document that each individual responsible for providing TAKE CHARGE services is trained on all aspects of the TAKE CHARGE program;
(h) If requested by the medicaid agency, participate in the research and evaluation component of the TAKE CHARGE demonstration and research program;
(i) If requested by the client, forward the client's services card and any related information to the client's preferred address within five working days of receipt;
(j) Inform the client of his or her right to seek services from any TAKE CHARGE provider within the state; and
(k) Refer the client to available and affordable nonfamily planning primary care services, as needed.
(2) Medicaid agency providers who are not TAKE CHARGE providers, (such as pharmacies, labs, and surgeons performing sterilization procedures) may give family planning pharmacy services, family planning lab services, and sterilization services to TAKE CHARGE clients.
[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.]



182-532-740
TAKE CHARGE program—Covered yearly exams for women.

(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.
[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.]



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.
[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.]



182-532-745
TAKE CHARGE program—Covered services for men.

The medicaid agency covers all the following TAKE CHARGE services for men:
(1) Over-the-counter (OTC) contraceptive supplies, as described in chapter 182-530 WAC.
(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 infections (STI), including lab tests and procedures, only when the screening and treatment are related to and medically necessary for a sterilization procedure.
(4) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence.
(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 TAKE CHARGE-trained providers (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.
[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.]



182-532-750
TAKE CHARGE program—Noncovered services.

(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 clients to safely and effectively use, or continue to use, 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.)
[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.]



182-532-760
TAKE CHARGE program—Documentation requirements.

In addition to the documentation requirements in WAC 182-502-0020, TAKE CHARGE providers must keep the following records:
(1) The signed supplemental TAKE CHARGE agreement to participate in the TAKE CHARGE program;
(2) Documentation of the medicaid agency's specialized TAKE CHARGE training and/or in-house TAKE CHARGE training for each individual responsible for providing TAKE CHARGE;
(3) TAKE CHARGE application form(s), along with supporting documentation if provided;
(4) Chart notes 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 followup;
(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) If applicable, a copy of the completed medicaid agency-approved sterilization consent form. (See WAC 182-531-1550 for more details about sterilization and the consent form.)
[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.]



182-532-780
TAKE CHARGE program—Reimbursement and payment limitations.

(1) The 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 clients to safely and effectively use, or continue to use, their chosen contraceptive methods.
(2) The medicaid agency reimburses TAKE CHARGE providers for covered TAKE CHARGE services using the agency's published 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 medicaid agency limits reimbursement for TAKE CHARGE research and evaluation activities to selected research sites.
(7) Federally qualified health centers (FQHCs), rural health centers (RHCs), and Indian health providers who are TAKE CHARGE providers must bill the medicaid agency for TAKE CHARGE services without regard to:
(a) Their special rates and fee schedules; or
(b) The encounter rate structure.
(8) The medicaid agency requires TAKE CHARGE providers to meet the billing requirements of WAC 182-502-0150.
(9) 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) and 182-532-790.
[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.]



182-532-790
TAKE CHARGE program—Good cause exemption from billing third party insurance.

(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.
[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.]