Part I
Family Planning Waiver

12VAC30-135-10. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Creditable health coverage" means "creditable coverage" as defined under §2701(c) of the Public Health Service Act (42 USC §300gg(c)) and includes coverage that meets the requirements of §2103 provided to a targeted low-income child under Title XXI of the Social Security Act or under a waiver approved under §2105(c)(2)(B) (relating to a direct service waiver).

"FDA" means the Food and Drug Administration.

"Family planning" means those services necessary to prevent or delay a pregnancy. It shall not include services to promote pregnancy such as infertility treatments. Family planning does not include counseling about, recommendations for or performance of abortions, or hysterectomies or procedures performed for medical reasons such as removal of intrauterine devices due to infections.

"FAMIS" means the Family Access to Medical Insurance Security Plan described in 12VAC30-141.

"Over-the-counter" means drugs and contraceptives that are available for purchase without requiring a physician's prescription.

"Third party" means any individual entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under the State Plan for Medical Assistance.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 25, eff. October 1, 2003; amended, Virginia Register Volume 23, Issue 21, eff. November 1, 2007; amended, Volume 24 Issue 26, eff. October 16, 2008.

12VAC30-135-20. Administration and eligibility determination.

A. The Department of Medical Assistance Services shall administer the family planning demonstration waiver services program under the authority of §1115(a) of the Social Security Act and 42 USC §1315.

B. Local departments of social services or a department contractor shall be responsible for determining eligibility of and for enrolling eligible individuals in the family planning waiver. Local departments of social services or a department contractor shall conduct periodic reviews and redeterminations of eligibility at least every 12 months while recipients are enrolled in the family planning waiver.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 25, eff. October 1, 2003; amended, Virginia Register Volume 23, Issue 21, eff. November 1, 2007; amended, Volume 24 Issue 26, eff. October 16, 2008.

12VAC30-135-30. Eligibility.

A. To be eligible under the family planning waiver, an individual must meet the eligibility conditions and requirements found in 12VAC30-40-10, have family income less than or equal to 133% of the federal poverty level, not have creditable health coverage, and not be eligible for enrollment in a Medicaid full benefit coverage group or FAMIS.

B. Individuals who have received a sterilization procedure or hysterectomy are ineligible under the waiver.

C. Individuals enrolled in the family planning waiver will not be retroactively eligible.

B. D. A recipient's enrollment in the family planning waiver shall be terminated if the individual receives a sterilization procedure or hysterectomy or is found to be ineligible as the result of a reported change or annual redetermination. The recipient's enrollment in the family planning waiver also shall be terminated if a reported change or annual redetermination results in eligibility for Virginia Medicaid or ineligibility for the family planning waiver in a full benefit coverage group or eligibility for FAMIS. A 10-day advance notice must be provided prior to cancellation of coverage under the family planning waiver unless the individual becomes eligible for a full benefit Medicaid covered group or FAMIS.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 25, eff. October 1, 2003; amended, Virginia Register Volume 23, Issue 21, eff. November 1, 2007; amended, Volume 24 Issue 26, eff. October 16, 2008.

12VAC30-135-40. Covered services.

A. Services provided under the family planning waiver are limited to:

1. Family planning office visits including annual gynecological or physical exams (one per 12 months), sexually transmitted diseases (STD) testing (limited to the initial family planning encounter), Pap cervical cancer screening tests (limited to one every six months);

2. Laboratory services for family planning and STD testing;

3. Family planning education and counseling;

4. FDA approved contraceptives Contraceptives approved by the Food and Drug Administration, including diaphragms, contraceptive injectables, and contraceptive implants;

5. Over-the-counter contraceptives; and

6. Sterilizations, not to include hysterectomies. A completed sterilization consent form, in accordance with the requirements of 42 CFR Part 441, Subpart F, must be submitted with all claims for payment for this service.

B. Services not covered under the family planning waiver include, but are not limited to:

1. Performance of, counseling for, or recommendations of abortions;

2. Infertility treatments;

3. Procedures performed for medical reasons;

4. Performance of a hysterectomy; and

5. Transportation to a family planning service.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 25, eff. October 1, 2003; amended, Virginia Register Volume 23, Issue 21, eff. November 1, 2007; amended, Volume 24 Issue 26, eff. October 16, 2008.

12VAC30-135-70. Reimbursement.

A. Providers will be reimbursed on a fee-for-service basis.

B. All reasonable measures including those measures specified under 42 USC §1396 (a) (25) will be taken to ascertain the legal liability of third parties to pay for authorized care and services provided to eligible recipients.

C. A completed sterilization consent form, in accordance with the requirements of 42 CFR Part 441, Subpart F, must be submitted with all claims for payment for sterilization procedures.

Statutory Authority

§32.1-325 of the Code of Virginia and Item 325 M of Chapter 899 of the 2002 Acts of Assembly.

Historical Notes

Derived from Virginia Register Volume 19, Issue 25, eff. October 1, 2003; amended, Volume 24 Issue 26, eff. October 16, 2008.