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H09-036 – Procedure

June 29, 2009

|TO: |Area Agency on Aging (AAA) Directors |

| |Home and Community Services (HCS) Division Regional Administrators |

| |Division of Developmental Disabilities (DDD) Regional Administrators |

|FROM: |Bill Moss, Director, Home and Community Services Division |

| |Linda Rolfe, Director, Division of Developmental Disabilities |

|SUBJECT: |Health and Recovery Services Administration (HRSA) Benefit Changes |

|Purpose: |To update Aging and Disability Services Administration (ADSA) staff regarding the HRSA Medicaid benefits |

| |changes. These changes include: |

| |Durable Medical Equipment (DME) Coverage |

| |Oral Enteral Nutrition Coverage |

| |Prescription Drug Program (Select Drugs) |

|Background: |The 2009-2011State Budget changed, reduced or eliminated some DME and oral enteral nutrition benefits for |

| |Medicaid recipients (children and adults). In addition, new limits and off-label use of two medications |

| |pertinent to the ADSA population are being implemented. |

|What’s new, changed, or |2009-2011 DME Benefits Changes |

|Clarified | |

| |Updated Information 07/01/09 |

| |Incontinent Supplies |

| |All DME attachments, client letters, and fact sheets referencing incontinence supply limits should have |

| |included the following language. The information omitted is in reference to liners. |

| |Limited to 200 per month regardless of age.  This includes briefs and liners or a combination of pull-ups and|

| |briefs and liners. |

| |All other existing limits on these supplies stay the same. |

| | |

| | |

| |For Adults: |

| |Deems bath or shower items, stockings, auto blood pressure cuffs as non-covered with Exception to Rule (ETR) |

| |option per WAC 388-501-0160; |

| |Deems oral enteral nutrition non-covered; allows it for tube feedings only. Offers Exception to Rule (ETR) |

| |option per WAC 388-501-0160; |

| |Limits diabetic supplies, with Limitation Extension (LE) option, to: |

| |Lancets and test strips 100/month if the client is on insulin; |

| |Lancets and test strips 100/3 months if the client is not on insulin; |

| | |

| |Limits incontinent supplies to 200 per client per month, tightening the current limit of 240 with a LE |

| |option; |

| |Limits non-sterile gloves to 200 per client per month with an LE option. This is a reduction from the |

| |current limit of 900 with no medical necessity criteria; |

| |Limits sterile gloves to 30 per month with an LE option. |

| | |

| |For Children: |

| |There are no new “non-covered” services; |

| |Allows enteral nutrition per the current program; |

| |Limits diabetic supplies with LE option to: |

| |Lancets and test strips 100/month if the client is on insulin; |

| |Lancets and test strips 100/3 months if the client is not on insulin; |

| | |

| |Limits incontinent supplies to 200 per client per month, tightening the current limit of 300 with a LE |

| |option; |

| |Limits non-sterile gloves to 200 per client per month with an LE option. This is a reduction from the |

| |current limit of 900 with no medical necessity criteria; |

| |Limits sterile gloves to 30 per month with an LE option. |

| | |

| |Exception to Rule: The prior authorization process used by HRSA to consider the appropriateness of a |

| |non-covered item when that service is specifically needed for that client because their clinical needs are so|

| |different than the rest of the population. |

| | |

| |Limitation Extension: The prior authorization process used to consider when it is medically necessary to |

| |allow more products for a specific client because their healthcare needs are not being met by the amount |

| |allowed in the base benefit for that service. |

| | |

| |2009 Drug Benefit Changes/Limitations on Certain Drugs |

| | |

| |New Limits on Seroquel/Seroquel XR (quetiapine fumarate)* |

| |(used for treatment of bipolar disorders and schizophrenia) |

| |Beginning July 1, 2009, DSHS will require prior authorization for prescriptions of Seroquel/Seroquel XR dosed|

| |daily at 50mg or less. Doses < 50mg/day are sub-therapeutic for the FDA approved indications, and there is |

| |little evidence to support the efficacy and safety of Seroquel for off-label uses at this dosage. Low dose, |

| |off-label use of Seroquel as a sedative-hypnotic will not be authorized. Food and Drug |

| |Administration-approved sedatives and hypnotics would be authorized according to HRSA’s pharmacy policy as a |

| |therapeutic alternative (see attachments for more information). |

| | |

| |New Limits on Lamictal (lamotrigine)*(used for treatment of epilepsy/seizures and treatment of bipolar |

| |disorder) |

| |Beginning July 1, 2009, DSHS will automatically authorize lamotrigine for FDA approved indications. Prior |

| |authorization will be required for all off-label use. Prescribers who have patients currently receiving |

| |Lamictal for off-label indications will be asked to prescribe an alternative medication. DSHS will provide |

| |authorization to facilitate a two-month taper off lamotrigine (see attachments for more information). |

| |Communication with clients, vendors and providers |

| |HRSA has mailed clients affected by the benefit changes written notification of the benefit non-coverage or |

| |benefit allowed amount coverage. |

| | |

| |HRSA has mailed contracted vendors who provide DME and enteral supplies notification informing them of |

| |benefit non-coverage and benefit allowed amount coverage changes. |

| |(Please see attachments for HRSA Client and Vendor Notification Letters.) |

| | |

| |What alternatives are available for clients who will no longer be able to receive oral enteral nutrition paid|

| |by Medicaid? |

| |Clients can: |

| |Consult with dieticians either with a physician referral using their medical card or through contracted |

| |dieticians using the following waiver services: |

| |Caregiver /Recipient Training (HCS) |

| |Staff and Family Consultation (DDD) |

| | |

| |Apply for food stamp assistance or other nutrition assistance programs (see the Basic Food Outreach |

| |Contractors attachment). |

| | |

| |Have formal and informal caregivers prepare nutritious meals and snacks. The US Department of Agriculture |

| |dietary guidelines are attached as a reference to provide to clients and caregivers (see the attached |

| |resources). |

| | |

| |The following waivers cannot be used to purchase enteral nutrition products as a medical supply; |

| |Community Options Program Entry System (COPES) |

| |Medically Needy In-Home and Medically Needy Residential |

| |Basic |

| |Basic Plus |

| |Core |

| |Community Protection |

| | |

| |The following waivers may be used to purchase oral enteral nutrition for products or amounts not covered: |

| |New Freedom |

| |Children’s Intensive In-Home Behavioral Supports (Oral enteral nutrition is allowable for children. Use the |

| |CIIBS waiver only when needed as an extension of the state plan benefit). |

| | |

| |Clients who no longer meet the eligibility through their medical cards would not be able to use the cost of |

| |purchasing the nutritional supplement as a reduction. Participation reductions allow only medical costs to be|

| |considered, and oral enteral nutrition products are considered food, and covered under the food assistance |

| |program. |

| | |

| |What items are included under bathroom or shower equipment for DME? |

| |Commode chairs |

| |Tub stool or bench |

| |Transfer bench for tub or toilet |

| |Bed pans |

| |Urinals |

| |Shower/commode chair |

| |Bath seats/chairs |

| |Potty chairs |

| |What actions do I need to take for my clients who are determined ineligible for oral enteral nutrition |

| |products? |

| |For clients who are no longer going to receive oral enteral nutritional products, effective July 1, 2009, the|

| |CARE nutritional/oral, eating and meal preparation screens should be updated as necessary to identify changes|

| |to the assessment and service planning needs for clients, including the use of oral nutritional supplements. |

|ACTION: | |

| |Social workers/case management/field staff will: |

| |Review clients affected by this change who may have a medical need to continue use of this product and assist|

| |clients as requested to obtain medical evaluations for determination of nutritional status and dietary |

| |recommendations. |

| |Evaluate the Negotiated Service Agreement or the Individual Service Plan with residential providers or |

| |agencies to ensure adequate nutrition resources and planning by the facility. |

| |Consult with AAA/HCS/DDD Nursing Services resources as needed for nutritional information and alternatives, |

| |service planning support and recommendations. Referrals for Nursing Services can be made at any time for |

| |consultation and assessment. |

| |Refer to community dieticians, as needed, for nutritional consultation. |

| |Refer clients to the Basic Food Outreach Program for assistance with Food Stamp applications. |

| | |

| |What actions do I need to take for my client whose health care provider has recommended bathroom or shower |

| |equipment? |

| |Consider whether the client’s need may be met through any of the HCS/DDD waivers for coverage of medical |

| |supplies and/or therapy consultations. |

| | |

| |Clients on the New Freedom waiver can consider using their monthly service budget for DME items no longer |

| |covered, or for extension of allowable amounts. |

|Related |WAC 388-530-2000 Prescription Drugs (outpatient) covered |

|REFERENCES: |WAC 388-530-2100 Prescription Drugs (outpatient) non-covered |

| |Chapter 388-554 WAC, Enteral Nutrition |

| |WAC 388-543-1150 Limits and limitation extensions |

| |WAC 388-543-1600 Items and services which require prior authorization |

| |WAC 388-543-2300 Bathroom/shower equipment |

| |WAC 388-501-0160 Exception to rule -- Request for a non covered healthcare service. |

| |Fruit and Vegetable Shake Recipes (Center for Disease Control) |

| |The Food Pyramid |

| | |

|ATTACHMENT(S): |2009 Fact Sheet New Limits on Seroquel/ Seroquel XR: |

| |[pic] |

| | |

| | |

| | |

| | |

| |2009 Fact Sheet New Limits on Lamotrigine (Lamictal): |

| |[pic] |

| |2009-2011 DME Benefit Changes: |

| |[pic] |

| |DME Benefits Fact Sheet: |

| |[pic] |

| |HRSA Client Notification Letter – Oral Enteral Nutrition: |

| |[pic] |

| |Letter to Medicaid Medical Suppliers: |

| |[pic] |

| |DME Letter to Clients: |

| |[pic] |

| |DSHS Medical Supply News Release: |

| |[pic] |

| |Basic Food Outreach Contractors: |

| |[pic] |

| |Finding Your Way to a Healthier You: |

| |[pic] |

| |Good Nutrition: It’s a Way of Life: |

| |[pic] |

| |High Calorie Recipes (Harborview Medical Center): |

| |[pic] |

| |Shopping Solutions for Healthy Eating: |

| |[pic] |

| |FAQs: Oral Enteral Nutrition: |

| |[pic] |

| |Oral Enteral Nutrition Poster: |

| |[pic] |

|CONTACT(S): |For questions regarding HRSA Enteral Nutrition benefits: |

| |Maureen Guzman 360-725-2033 |

| |guzmam@dshs. |

| | |

| |For questions regarding HRSA DME benefits: |

| |Erin Mayo |

| |360-725-1729 |

| |mayoe@dshs. |

| | |

| |For questions regarding HRSA Pharmacy benefits: |

| |Siri Childs |

| |360-725-1564 |

| |childsa@dshs. |

| | |

| |For questions regarding DDD Case Management: |

| |Debbie Johnson |

| |360-725-3525 |

| |johnsda2@dshs. |

| | |

| |For questions regarding HCS Waiver services: |

| |Marilee Fosbre |

| |360-725-2536 |

| |fosbrma@dshs. |

| | |

| |For questions regarding DDD Waiver Services: |

| |Kris Pederson |

| |360-725-3445 |

| |pederkn@dshs. |

| | |

| |For questions regarding nutritional resource, pharmacy or Nursing Services: |

| |Candace (Candy) Goehring |

| |360-725-2562 |

| |goehrcs@dshs. |

| | |

| |For Residential Provider concerns contact the Complaint Resolution Unit: |

| |1-800-562-6078 |

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