Access Washington Home
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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