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H05-090 – Procedure

October 31, 2005

|TO: |Area Agency on Aging Directors |

| |Home and Community Services Regional Administrators |

| |Division of Developmental Disabilities Field Services Administrators |

|FROM: |Penny Black, Director, Home and Community Services Division |

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

|SUBJECT: |Health and Recovery Services Administration (HRSA) Implements new Requirements for Liquid Supplements October|

| |1, 2005 |

|Purpose: |To update Aging and Disability Services Administration (ADSA) staff regarding the implementation of the new |

| |HRSA (formerly Medical Assistance Administration) eligibility requirements for orally administered nutrition |

| |products effective October 1, 2005. |

|Background: |WAC 388-554-100 through 388-554-800 contains the eligibility criteria established by HRSA for clients to |

| |receive oral enteral nutrition products. The implementation of this Washington Administrative Code (WAC), |

| |and subsequent eligibility changes had been delayed until October 1, 2005 to allow clients, vendors and |

| |physicians more opportunity to prepare for this eligibility change. |

| | |

| |ADSA staff have been following the direction provided in MB H05-030 and have been working with ADSA clients |

| |identified as using oral enteral nutritional products during the time period February 2004 through February |

| |2005. The interventions included providing information about the new program requirements, assisting as |

| |necessary with the authorization process, updating CARE as needed to reflect changes in service planning or |

| |care needs, and providing alternative nutritional resource information when indicated. |

|What’s new, changed, or |Screening and authorization of Medicaid clients to determine eligibility for oral enteral nutritional |

|Clarified: |products is based on medical necessity, and can be found in WAC 388-554-100 through 800. Documentation |

| |supporting medical necessity includes factors such as diagnosis, lab values, Body Mass Index (BMI) for |

| |adults, percentile of growth for infants and children, and weight loss history. Determination of medical |

| |necessity and authorization by HRSA staff is required prior to a client receiving these products from a |

| |vendor. |

| | |

| | |

| |Prior to the implementation date of October 1, 2005, HRSA compiled an updated list of those clients who had |

| |Medicaid billing for oral enteral nutrition from June 2005 through September 2005, and have not had an |

| |authorization request submitted for review and determination of eligibility. Those clients were sent a notice|

| |from HRSA on September 29, 2005 (attached), notifying the client: |

| |Of the change requiring a medical need for the product; |

| |That HRSA had not had a medical necessity request submitted for that client for review; and |

| |Regarding important information for the client on steps they can take; for example, getting emergency |

| |supplies and calling their doctor or vendor. |

| | |

| |ADSA has also received this new list of clients who had Medicaid billing for the oral nutritional products in|

| |the last 120 days and had not had an authorization request submitted to HRSA. The respective list for each |

| |Reporting Unit will be sent under separate email to each unit. This list will identify the clients who: |

| |Have had a billing for oral enteral nutrition in the last 120 days; |

| |Have not had an authorization request submitted; and |

| |Will be marked with a “Y” in the last column if this client was not on the list sent out to Reporting Units |

| |in April 2005. |

|ACTION: |Each Region/AAA/Field office will notify social worker/case management staff of their clients identified as |

| |having received this product in the last 120 days, but not having an authorization request submitted to HRSA |

| |for review. |

| | |

| |Social work/case management/field staff will need to review this list for clients with greatest need such as |

| |history of weight loss, poor dentition, dementia, inability to chew or swallow, and provide assistance as |

| |needed with the authorization process based on medical necessity of the client. |

| | |

| |All other clients should have their nutritional status reviewed at their next assessment or other normally |

| |occurring collateral contact to determine oral intake, use of oral enteral supplemental products, or other |

| |nutritional resource needs. Assessment documentation may include; |

| | |

| |Client assessment reviewed and updated as needed for oral enteral nutrition; |

| |Client’s medical need for oral enteral nutrition; |

| |Assistance provided for client with HRSA authorization process; or |

| |Client is no longer using the oral nutritional product. |

| | |

| |Consultation with AAA/HCS/DD Nursing Services as needed for nutritional resources and information. |

| | |

| |Referral to community dieticians as needed for nutritional consultation. |

|Related |[pic] [pic] |

|REFERENCES: | |

|ATTACHMENT(S): |[pic]HRSA Client Notice (09/29/05) |

|CONTACT(S): |For questions regarding HRSA Oral Enteral Nutrition program or eligibility: |

| |Olin Cantrell |

| |360-725-1676 |

| |cantrow@dshs. |

| | |

| |For questions regarding ADSA interventions or programs contact: |

| |Candace Goehring |

| |360-725-2562 |

| |goehrcs@dshs. |

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