WAC 182-532-540 Family planning only program - Noncovered services

WAC 182-532-540 Family planning only program—Noncovered services

Effective September 1, 2013

  1. Medical services are not covered under the family planning only program unless those services are:
    1. Performed in relation to a primary focus and diagnosis of family planning; and
    2. 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.)

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-533 Family planning only program - Other covered services

WAC 182-532-533 Family planning only program—Other covered services

Effective September 1, 2013

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:
    1. For chlamydia and gonorrhea as part of the comprehensive prevention visit for family planning for women ages thirteen through twenty-five; or
    2. 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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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

Effective October 1, 2019

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-510 Family Planning only program - Client eligibility

WAC 182-532-510 Family planning only program—Client eligibility

Effective May 8, 2025

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.

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

  1. 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);
  2. Be a Washington state resident, as described under WAC 182-503-0520;
  3. Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
  4. Need family planning services; and
  5. Have been denied apple health coverage within the last 30 days, unless the applicant:
    1. Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;
    2. Is age 26 or younger and seeking services in confidence;
    3. Is a domestic violence victim who is seeking services in confidence; or
    4. Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.
  6. A client is not eligible for family planning only medical if the client is:
    1. Pregnant;
    2. Sterilized;
    3. Covered under another apple health program that includes family planning services; or
    4. Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) of this subsection.
  7. The agency does not limit the number of times a client may reapply for coverage.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-125 Reproductive health - Covered services for men

WAC 182-532-125 Reproductive health—Covered services for men

Effective September 1, 2013

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-123 Reproductive health - Other covered services for women

WAC 182-532-123 Reproductive health—Other covered services for women

Effective September 1, 2013

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-120 Reproductive health - Covered yearly exams for women

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

Effective September 1, 2013

  1. Along with services listed in WAC 182-531-0100, the medicaid agency covers one of the following yearly exams per client per year:
    1. A cervical, vaginal, and breast cancer screening exam; or
    2. 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:
    1. Must follow the guidelines of a nationally recognized protocol; and
    2. May be billed by a provider other than a TAKE CHARGE provider.
  3. The comprehensive prevention visit for family planning:
    1. Must be provided by one or more qualified TAKE CHARGE providers. (See WAC 182-532-730.)
    2. Must include:
      1. A clinical breast examination and pelvic examination that follows the guidelines of a nationally recognized protocol; and
      2. Client-centered counseling that incorporates risk factor reduction for unintended pregnancy and anticipatory guidance about the advantages and disadvantages of all contraceptive methods.
    3. May include a pap smear according to current, nationally recognized clinical guidelines.
    4. Must be documented in the client's chart with detailed information that allows for a well-informed follow-up visit.
    5. Must be billed by a TAKE CHARGE provider only.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-100 Reproductive health services - Eligibility.

WAC 182-532-100 Reproductive health services -- Eligibility

Effective October 1, 2019

  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 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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0300 Order of dismissal based on subject matter

WAC 182-526-0300 Order of dismissal based on subject matter

Effective March 16, 2017

  1. An order of dismissal issued based on lack of subject matter jurisdiction must be entered as an initial order subject to the requirements of WAC 182-526-0520.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0284 Orders of default

WAC 182-526-0284 Orders of default.

Effective August 18, 2018

  1. An order of default may be entered when the appellant fails to attend a scheduled prehearing conference or hearing. The order of default will include a notice of inquiry as to whether the appellant wants to petition to reinstate the hearing.
  2. The appellant may file a petition to vacate an order of default under WAC 182-526-0290.
  3. An order of default becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if:
    1. The appellant does not file a petition to vacate within twenty-one calendar days of the order being served (mailed) on the parties under WAC 182-526-0290 (2) and (5)(b); or
    2. If the appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4)(a).
  4. The health care authority or managed care organization action stands after an order of default becomes a final order.
  5. The appellant may seek judicial review of a final order of default to the superior court under WAC 182-526-0640.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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