WAC 182-551-1000 Hospice program—General

Effective May 18, 2012

1. The medicaid agency's hospice program is a twenty-four hour a day program that allows a terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort care and a focus on quality of life. A hospice interdisciplinary team communicates with the client's nonhospice care providers to ensure the client's needs are met through the hospice plan of care. Hospitalization is used only for acute symptom management.
2. A client, a physician, or an authorized representative under RCW 7.70.065 may initiate hospice care. The client's physician must certify the client as terminally ill and appropriate for hospice care.
3. Hospice care is provided in a client's temporary or permanent place of residence.
4. Hospice care ends when:
   1. The client or an authorized representative under RCW 7.70.065 revokes the hospice care;
   2. The hospice agency discharges the client;
   3. The client's physician determines hospice care is no longer appropriate; or
   4. The client dies.
5. Hospice care includes the provision of emotional and spiritual comfort and bereavement support to the client's family member(s).
6. Medicaid agency-approved hospice agencies must meet the general requirements in chapter 182-502 WAC, Administration of medical programs—Providers.

WAC 182-546-0150 Client eligibility for ambulance transportation

Effective July 6, 2018

1. Except for people in the Family Planning Only and TAKE CHARGE programs, fee-for-service clients are eligible for ambulance transportation to covered services with the following limitations:
   1. People in the following Washington apple health programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 182-501-0175:
      1. Medical care services (MCS) as described in WAC 182-508-0005;
      2. Alien emergency medical (AEM) services as described in chapter 182-507 WAC.
   2. People in the apple health categorically needy/qualified medicare beneficiary (CN/QMB) and apple health medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC 182-546-0400(5).
2. People enrolled in an agency-contracted managed care organization (MCO) must coordinate:
   1. Ground ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter; and
   2. Air ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter.
3. People enrolled in the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with the agency's requirements. The agency pays for covered services for these people according to the agency's published billing guides and provider alerts.
4. People under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to people who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC 182-546-4000.
5. See WAC 182-546-0800 and 182-546-2500 for additional limitations on out-of-state coverage and coverage for people with other insurance.
6. The agency does not pay for ambulance services for jail inmates and people living in a correctional facility, including people in work-release status. See WAC 182-503-0505(5).

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

Effective September 1, 2013

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.

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.

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

Effective September 1, 2013

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.

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

Effective September 1, 2013

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.

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.