006 Enclosure

							MEDICAL ASSISTANCE ADMINISTRATION
Medicaid sets higher standards
for enteral nutrition programs
BACKGROUND: The medical assistance administration’s
(MAA’s) enteral nutrition program covers medically necessary
products, equipment and supplies. Washington is one of 33 states
that cover oral nutrition support without restrictions. Three
states and the federal Medicare program do not cover oral
nutrition at all. Another 14 states cover it rarely and primarily
for children. One-third of Washington’s enteral nutrition clients are children; two-thirds
are adult.

THE KEY ISSUE: By Legislative mandate, MAA must reduce DME expenditures by 5%. A
review of the utilization of the oral nutrition products demonstrated that 5,575 claims for 6,334
clients were submitted with diagnoses not necessarily consistent with the need for oral nutrition
support. These cases involved a total expenditure of $10.7 million for oral nutrition products.
MAA reimburses for enteral nutrition to meet the nutritional and caloric needs required to sustain
the health of an eligible medical assistance client when defined as medically necessary by the
department.

UTILIZATION MANAGEMENT STRATEGIES: In order to achieve this mandated
reduction in costs, MAA is implementing a prior authorization program for oral enteral nutrition.
To assure clients receive medically necessary interventions providers are required to obtain prior
authorization or expedited prior authorization. The program will include the following
considerations:

1. All oral nutrition products:
     (a). Clients with cancer requiring chemotherapy; chronic renal failure undergoing dialysis;
      or pressure/decubitus ulcers at stage 3 or greater will require expedited prior authorization.

     (b). All other requests except as specified in 1 (a) above will be subject to preauthorization
      to assure the treatment is properly prescribed and medically necessary, consistent with
      MAA’s protocols and criteria.

 2. This new program does not affect the program requirements for clients receiving nutritionals
through a tube into the stomach or small intestine. These nutrition products are exempt from any
prior authorization requirements, supplies and equipment will continue to require prior
authorization or expedited prior authorization.

MAA’s plan is to implement these changes with a minimum of disruption of care. Washington
Administrative Code (WAC) and billing instructions (BI) will be distributed approximately
March 2005

For further information please contact the program manager at 360 725 1676.